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Patient Health Survey

We welcome the chance to participate in your care.  We have asked your physician to evaluate your health and order the appropriate studies.  We will depend on you to provide accurate health screening information on this form.

Please complete the following information as fully as possible.  Thank you for your help.

Patient Health Survey

Patient Health Survey
  • id
  • date
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  • First Name:
  • Last Name:
  • Date of birth:
  • Height:
  • Weight:
  • Procedure:
  • Date of Surgery:
    calendar
  • Name of person driving you home:
  • Do you have a communication barrier?
  • If you have a communication barrier, please select the type(s):

  • If you selected "Other" for communication barrier type, please describe your communication barrier:
  • Do you understand both spoken and written English?
  • If you answered "No" to the previous question, please complete the following two (2) questions.
  • What is your preferred spoken language?
  • What is your preferred language for reading?
  • Communication tools needed:

  • If you selected "Other" for the previous question, please describe the communication tool needed:
Medical History
  • Please list all operations with the date:
  • Did you ever vomit after surgery?
  • Please list all medical illnesses with the date of onset and/or discovery:
  • Please list all prescription and over the counter medications you currently take, including dosage amount and frequency: (if you are not currently taking any medications, please enter "none")
  • Have you ever had any of the following conditions:

  • If you have any of the previous conditions, please add additional information or comments.
  • Are you allergic to any of the following items?

  • Please list all allergies with a brief description of the reaction:
  • Have you ever had a problem with anesthesia?
  • Please describe your last anesthesia experience:
  • Has anyone related to you ever had a problem with anesthesia?
  • Please describe your relative's anesthesia experience:
  • Did you ever vomit after surgery?
  • Please describe your experience with post surgical vomiting.
  • Do you currently have an open wound?
  • Please note the location of the open wound:
  • Do you have any problems with your neck or with opening your mouth?
  • Please describe any problems with your neck or opening your mouth.
  • Do you have back problems?
  • Please describe your back problems.
  • Could you be pregnant?
  • Please provide the date of your last menstrual period.
  • Do you wear contact lenses?
  • Do you have dentures, caps or braces?
  • If you have any of the previous dental appliances/additions, please describe.
  • Do you have any jewelry or piercings that can not be removed?
  • If yes, please elaborate:
  • Do you use recreational drugs?
  • If you use recreational drugs, please list the type, amount and frequency of use.
  • Do you drink alcohol?
  • If you drink alcohol, please list the amount, frequency and type of alcohol consumed.
Heart History Information
  • Have you ever had a heart attack?
  • Please list any additional information or comments about your heart attack.
  • Do you have any of the following conditions:

  • Please add any additional information or comments about your heart condition(s).
Lung History Information
  • Have you ever smoked?
  • If you have ever smoked, please list how much per day, as well as how many years you have smoked.
  • Do you have any of the following conditions:

  • If you have any lung conditions, please list any additional information or comments.
Blood Health History Information
  • Have you or anyone in our family ever had a serious bleeding problem or diagnosed blood disorder?
  • Please describe any family bleeding problems or blood disorders.
  • Have you ever been anemic or received a blood transfusion?
  • Please add any additional information or comments if you have ever been anemic or received a blood transfusion, including the date of the transfusion and the location where it was performed.
  • Have you had hepatitis or been jaundiced?
  • If you have been jaundiced or anemic, please list additional information or comments.
  • Have you ever been exposed to anyone with hepatitis?
  • If you have been exposed to anyone with hepatitis, please describe the exposure.
Neurological History Information
  • Have you ever had any of the following neurological conditions:

  • If you have ever had any of the listed neurological conditions, please add any additional information or comments.
Psych and Social History Information
  • Please list any additional questions or concerns you have about your procedure.
  • Please list any questions or concerns about home care after your procedure.
  • Please list any spiritual, cultural or psychosocial needs related to your care.
  • If you are under the care of a psychiatrist or other mental healthcare professional, please list their name and contact information.
  • If you are being hurt by someone you know or love, please explain.
  • If we may contact you by telephone at your home, please list the preferred number and the best times to reach you.
Additional Information
  • Do you have any of the following available?  If so, please bring a copy.

  • Would you like information on Advance Directives?
  • Please list any questions about your care that you would like to have answered.
  • If you have any physical or mental handicaps/limitations, please briefly describe them.