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Athens-Limestone Hospital

Pre-Admission Health History

  Name
  Street Address
  City, State, Zip Code
  Phone
  Email
  Date of your procedure/your doctor's name
Health History - If you have had any of the following, please check:
  Anemia
Arthitis
Asthma
Auto-Immune Disease
Bleeding Tendencies
Blood Clots
Brain Disorder
Cancer
Chronic Cough
Congestive Heart Failure (CHF)
Diabetes
Emphysema
Fibromyalgia
Hearing Impairment
Heart Disease
Irritable Bowel Syndrome (IBS)
Lung Disorder
Migraines/Headaches
Mitral Valve Prolapse
High Blood Pressure
Kidney Problems
Liver Disease/Hepatitis
Muscle Disease
Nervous Disorder/Disorder
Previous Transfusions
Reflux
Seizures
Sleep Apnea
Stroke
TB
Thyroid Problems
Ulcers
Unexplained Weight Loss
None of the Above
  Other:
Pediatric Patients Only: Have you been exposed in the last 2 weeks to:
  Chicken Pox
Measles
Meningitis
Strep
Ticks
Mumps
Other
  Immunizations current? Yes     No    
  Any Growth/Development Problems? Yes     No    
Required Patient Information:
  Last Menstrual Period:
  Have you had an EKG in the past 3 months? Yes     No    
  If yes, where?
  Flu Shot? Yes     No    
  If No, do you want one? Yes     No    
  If yes, what year?
  Pneumonia Shot? yes     no    
  If no, do you want one? Yes     No    
  Do you want information on Flu or Pneumonia shots? Yes     No    
  Do you wear glasses? Yes     No    
  Do you wear contacts? Yes     No    
  Do you wear hearing aids? Yes     No    
  Do you wear dentures? Yes     No    
  Appetite:
  Height:
  Weight:
  Alcohol: Yes     No    
  Amount:
  Smoker/Tobacco: Yes     No    
  Amount:
  Living Will? Yes     No    
  Would you like more information? Yes     No    
  Do you have a prosthesis?
Previous Surgeries:
  Appendix Removed
Back Surgery
Breast Biopsy
Breast Mastectomy
Carpal Tunnel
Cataract Surgery
Eye Surgery
C-Section
Colon Resection
D&C
EGD
Colonoscopy
Bladder Surgery
Exploratory Laparoscopy
Foot Surgery
Gallbladder
Gastric Bypass
Open Heart Surgery
Heart Stents
Hemorrhoidectomy
Hernia Repair
Hysterectomy
Joint Replacement
Kidney Stones
Lung Surgery
Tubes in Ears
Thyroid Removed
Prostate Surgery
Sinus Surgery
Tonsils Removed
Tubes Tied
Vasectomy
Shoulder Surgery
Knee Surgery
Neck Surgery
  Other:
Alergies:
  Drug: Yes     No    
  Food: Yes     No    
  Latex: Yes     No    
  Adhesives: Yes     No    
  List allergies & reaction that occurs:
  Medication List & Amount:
  Have you ever felt unsafe or threatened at home? Yes     No    
  Do you live:
  Home Situation:
  Currently using:
  Agency name?
  Education - do you learn best by: Verbal instruction
Reading/Written material
Demonstration
  Medical Equipent: Cane
Walker
Hospital Bed
C-pap
Nebulizer
Oxygen
Wheelchair
  Other:
  Which Pharmacy do you use?
  Contact person/Relationship?
  Phone # we can contact you?