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Surgery.med.sc.edu

Medical Information Database
Name: __________________________________________ Date: __________________
Reason for seeing doctor: ___________________________________________________
Referring Physician: _______________________________________________________
Were you seen in the Emergency Room? YES NO
___ Richland ___ Baptist ___ Lexington ___ Providence ___ Providence NE
___ Other
Date of accident or injury: _______________
If not accident or injury, date the symptoms began: __________________
Current physician, pediatrician, or family doctor, if you have one: __________________
Previous Medical History

List all known allergies: ____________________________________________________
________________________________________________________________________
Do you have a Latex Allergy/Sensitivity? YES NO
List all medications you are taking and reason you are taking it (including Aspirin,
Ibuprofen, Motrin, NSAID, Goody Powder, Vitamins, herbal Medication, etc.): _______
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
List any medications that you cannot take: _____________________________________
_______________________________________________________________________
Immunizations

Please indicate date (month and year) of last immunization.
Tetanus Booster ____________
Patient Name: ____________________________________ Date: __________________


Current Medical Problems

Please “X” YES or NO
YES NO
___ ___ Breast Disease
___ ___ Other, if any please explain: ________________________________________
Review of Systems

Please “X” YES or NO
YES NO

Previous Hospitalizations

Date
______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ Patient Name: ____________________________________ Date: __________________
Past Surgical History

Date

Social History

Do you use tobacco products of any kind? YES / NO Amount / Frequency: __________
Do you drink alcohol? YES / NO Amount / Frequency: __________________________
Do you use illegal drugs? YES / NO Amount / Frequency: _______________________
Occupation: _____________________________________________________________
Living Situation: _________________________________________________________
Family History

Please “X” YES or NO and relationship
YES NO Relationship
Reviewed and updated on _____________ By _________ Reviewed and updated on _____________ By _________

Source: http://surgery.med.sc.edu/patientcare/forms/Plastic%20Surgery%20Medical%20Information%20Database.pdf