CONFIDENTIAL MEDICAL HISTORY Patient Name: ___________________________________________________________ Please answer ALL questions. If you do not know the answer, or do not understand the question, insert a ? in the space. Nature of complaints: ____________________________________________________ GENERAL HEALTH
Do you smoke? ____ How many packs a day? ____ For how long? _____ Year quit ____ Alcoholic beverages per day: _____________ Coffee/Tea per day: __________________ Do you have any allergies to any medications? _________________________________ If so, what type of reaction do you have? ______________________________________ Any prior blood transfusions? _______________________________________________ PAST MEDICAL HISTORY
Do you have or have you ever had any major illness? (Diabetes, heart disease, high blood pressure, kidney disease, stroke, etc.) 1. ______________________________________________Year Diagnosed: __________ 2. ______________________________________________Year Diagnosed: __________ 3. ______________________________________________Year Diagnosed: __________ SURGICAL HISTORY
Operation
1. ______________________________________________________ Year: __________ 2. ______________________________________________________ Year: __________ 3. ______________________________________________________ Year: __________ 4. ______________________________________________________ Year: __________ 5. ______________________________________________________ Year: __________ 6. ______________________________________________________ Year: __________ 7. ______________________________________________________ Year: __________ 8. ______________________________________________________ Year: __________ 9. ______________________________________________________ Year: __________ 10. _____________________________________________________ Year: __________ Current Medications: ______________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Do you take Aspirin? ______________________________________________________ Do you take Coumadin? ____________________________________________________ Do you take Plavix? _______________________________________________________ Do you take Pradaxa? _____________________________________________________
Do you have or have you ever had: Abnormal bleeding or anemia……….Y N
Difficulty climbing stairs ………. Y N
Hypertension ………………………. Y N Ulcer or Gastritis………………. Y N Weight Loss …………………………Y N Difficulty swallowing …………… Y N Fits/convulsion/seizures……………. Y N Numbness ………………………. Y N Double vision ………………………. Y N Paralysis ………………………… Y N Sudden visual loss …………………. Y N Diabetes ………………………… Y N Decreased hearing …………………. Y N Stroke …………………………… Y N Shortness of breath ………………… Y N Heart surgery ……………………. Y N Loss of memory……………………. Y N Chest pain ………………………. Y N Metal in body ………………………. Y N Claustrophobia …………………. Y N Family History Any illnesses that run in the family: _________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Causes of death for immediate family members: _______________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ History of prior injuries (work related/ Non work related): Nature: _______________________________________________________________________ How treated: __________________________________________________________________ Year: _________________________________________________________________________ Nature: _______________________________________________________________________ How treated: __________________________________________________________________ Year: _________________________________________________________________________ Nature: _______________________________________________________________________ How treated: __________________________________________________________________ Year: _________________________________________________________________________ Signature _______________________________________________ Date: _________________
Early Perioperative Death Associated With ReexpansionPulmonary Edema During Liver Transplantation Wagner C. Marujo, Flavio Takaoka, Rita M. A. Moura, Fernando L. Pandullo, Andre R. Morrone, Marcelo M. Linhares, Alexandre Teruya, and Isaac Altikes Hydrothorax is a frequent finding in patients with end- REPE during a LT that rapidly led to the patient’s stage liver disease. During the he
Kathmandu University Medical Journal (2008), Vol. 6, No. 3, Issue 23, 370-374 Asthma and dental erosion Manuel ST1, Kundabaka M2, Shetty N3, Parolia A1 1Assisstant professor, 2Professor, 3Associate professor, Department of Conservative Dentistry and Endodontotics, Manipal College of Dental Science, Mangalore, India Abstract Asthma is a chronic inÀ ammatory condition of the airway, chara