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Mizell Memorial Hospital

Surgical Service Medical Questionnaire

Thank you for choosing Mizell Memorial Hospital's Surgical Services Department and for completing your medical questionnaire online.
Do not worry about listing the dates of surgeries, but be as detailed as possible as to how many, which side or what level if any. At the end of the questionnaire you will need to list your medications that you are presently taking on a daily basis. Be sure to list any herbal medications and any over the counter medications that you may also take routinely. If you have a large amount of medications to be listed and you purchase all your medications from one pharmacy then you may list the pharmacy name along with their phone number including the area code. Please bring your medications with you on the day of your procedure. By collecting this information ahead of time, it helps our staff determine if you are in need of further pre-operative work such as lab, EKG, cardiac clearance, x-rays, etc. A nurse from the Surgical Services Department will be contacting you one or two days (or earlier) prior to surgery. At this time she will review your health information, medications, tell you what time to arrive at the hospital and tell you what time to stop eating and drinking prior to your procedure. If you have any questions concerning this questionnaire or your procedure, please feel free to call us at 334-493-9139 (Monday - Friday 7:00 a.m. - 3:00 p.m.)
* Patient Name
Include first, middle & last name
* Date of Birth
Example: 02/04/1948
* Telephone Number
Example: (area code)999-9999
* Family Doctor
Include first and last name
* Surgeon
Include first and last name
* How tall are you?
____ft ____in
* How much do you weigh?
____lbs
* Do you wear glasses or contacts? yes     no    
* Do you need to use a cane or walker? no assistive device     cane     walker    
* Are you hard of hearing? yes     no    
* Do you have hearing aids? yes     no    
* Do you wear dentures or a partial plate? yes     no    
* Do you have a Living Will (Advanced Medical Directives)?
Information is available if needed.
yes     no    
* Do you have a prosthesis? yes     no    
  If you have a prosthesis, where is it?
* Have you had a flu vaccine this year? yes     no    
  If you had flu vaccine, list date of vaccine
* Have you had a pneumonia vaccine within the last 5 years? yes     no    
  If you had a pneumonia vaccine, list the date of vaccine
* Chief Complaint for procedure:
* Surgical History:
(Please indicate any surgeries you may have had previously, if a surgery is not listed then fill in on the lines below.)
None
Appendectomy
Adenoidectomy
Cataract
Carotid Endarectomy
Carpel Tunnel Release
C-section
Colon Resection
Cholecystectomy
CABG/Bypasses
Gastric Resection/Binding
Hysterectomy
Mastectomy
Neck
Pacemaker/Defibrillator
Pneumonectomy
Mediport
Nephrectomy
Shoulder
Sinus
T&A
Tonsillectomy
Hernia repair
Joint repair
* Other surgeries or if indicated hernia or joint repair then list type
* Do you have any ALLERGIES to MEDICATIONS OR FOODS? yes     no    
* If any allergies, what are the symptoms and how severe are they?
* Please list any psychological problems you may have such as anxiety, depression, bipolar disorder, schizophrenia, etc.
* Have you ever had a TIA or a stroke? yes     no    
* If you have had a stroke, please list when you had your stroke, what type of stroke (ischemic or bleed) and any residual effects from the strokes (such as paralysis, weakness).
* Have you been diagnosed with any type of dementia? yes     no    
* Do you suffer from osteoarthritis or rheumatoid arthritis? yes     no    
* Do you have a condition called neuropathy (numbness/tingling) in any of your extremities? yes     no    
* Have you been diagnosed with osteoporosis? yes     no    
* Do you have any contractures or amputations? yes     no    
* If you have any contractures or amptuations- if so, where?
* Do you take medication for high blood pressure? yes     no    
* Have you ever been told you have an irregular heart rhythm or a history of atrial fibrillation? yes     no    
* Do you have chest pain? yes     no    
* Have you ever had a heart attack? yes     no    
* Do you have a pacemaker or a debrillator? yes     no    
* Have you had a recent "cardiac workup" (stress test, EKG, blood work)? yes     no    
* Have you ever had a heart catherization or angioplasty? yes     no    
  If you answered yes, what were the results of the heart catherization or angioplasty?
* Have you ever had a DVT (deep vein thrombosis/blood clot)? yes     no    
* Do you smoke? yes     no    
* If you smoke, how much do you smoke a day?
* How many years have you smoked?
* Do you use smokeless tobacco?
* Have you ever been told you have COPD (Chronic Obstructive Pulmonary Disease) like emphysema or chronic bronchitis? yes     no    
* Do you have asthma? yes     no    
* Have you had a recent upper respiratory infection? yes     no    
* Have you recently had pneumonia or bronchitis? yes     no    
* Do you have a history of dyspnea (shortness of breath) or orthopnea (shortness of breath when lying down)? yes     no    
* Do you have a productive cough? yes     no    
* If you answered yes to a productive cough, describe what you cough up and how much it is.
* Do you have tuberculosis or a history of tuberculosis? yes     no    
* Do you have sleep apnea? yes     no    
* If you have sleep apnea, do you use a CPAP machine? yes     no    
* Do you have acid reflux? yes     no    
* Have you ever been told you have a hiatal hernia or gastric ulcers? yes     no    
* Do you vomit blood or pass blood in your stool? yes     no    
* Do you have difficulty swallowing or have esophageal strictures? yes     no    
* Do you have persistent nausea and/or vomiting? yes     no    
* Do you suffer from CHRONIC constipation or diarrhea? yes     no    
* Do you have a PEG/NG tube for feeding? yes     no    
Section to be completed for females:
  Do you still have a menstrual cycle? yes     no     NA    
  If yes, date of last menses:
  Are you pregnant? yes     no    
  If yes, gestational weeks:
Section to be completed for males:
  Do you have any problems with your prostate? yes     no     NA    
Section to be completed for males & females:
* Do you have any bladder or kidney problems? yes     no    
  If you are a renal failure patient on dialysis, please list any type of dialysis you are currently using.
* Have you personally had any type of cancer? yes     no    
  If had/has cancer, please list type:
* Do you suffer from high or low thyroid problems? yes     no    
* Do you have any liver problems? yes     no    
* Are you DIABETIC? yes     no    
* If you are diabetic, are you INSULIN DEPENDENT or do you take oral (by mouth) agents? Insulin dependent     Oral (by mouth)     not applicable    
* Does your blood sugar tend to drop (HYPOglycemia) when you do without food? yes     no    
* Do you have anemia (iron deficiency, pernicious or sickle cell)? yes     no    
* Have you ever had any type of infectious communicable disease like hepatitis, sexually transmitted diseases (STDs), tuberculosis, AIDS? yes     no    
* Are you a hemophiliac (free bleeder)? yes     no    
* Are you immunosuppressed (easily suspectible to germs)? yes     no    
* Have you taken steroid medication in the last 6 months? yes     no    
* Are you on a special diet? yes     no    
Pediatric Development History (0 to 13 years):
**Only answer questions pertaining to your childs age range
****Newborn to Infant Pediatric Development History****
  Does he/she lift head? yes     no    
  Does he/she roll over? yes     no    
  Does he/she hold bottle? yes     no    
  Does he/she sit alone? yes     no    
  Does he/she crawl? yes     no    
****1-3 Toddler Pediatric Development History****
  Does he/she walk alone? yes     no    
  Does he/she climb stairs? yes     no    
  Is he/she weaned from bottle? yes     no    
  Does he/she know several words? yes     no    
****3-5 Preschool Pediatric Development History****
  Does he/ride tricycle? yes     no    
  Does he/she walk on tiptoes? yes     no    
  Does he/she skip and hop? yes     no    
  Is he/she bladder trained? yes     no    
  Is he/she bowel trained? yes     no    
****6-13 School Pediatric Development History****
  Girls:
  Has she started menstrual cycle? yes     no    
****Pediatric Development History- The following questions MUST be answered for ALL children****
  Is there a history of birth complications? yes     no    
  Are all immunizations up to date? yes     no    
  If no, explain.
Medications:
* Please list all medications, including herbal and any over the counter
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This form can NOT be completed until you enter the text you see into the space below and click submit. If you have any problems or questions, contact 334-493-5511.