health questionnaire - Mount Sinai Hospital

E. SURGERY & ANESTHESIA HISTORY• Have you had any of the following types of surgery or procedures?I have never had surgeryHead/Neck: Brain Eyes Nose Tonsils Thyroid Throat Other ______________Chest: Heart Lungs Breast IV Catheter / Port Implant Esophagus Aorta Other____________Abdomen: Gall Bladder Appendix Colon Liver Stomach Kidney Pancreas Other_____________Pelvis: Hernia Uterus/Ovaries C-Section Bladder Prostate Other_______________Extremities: Knee Hip Shoulder Hand/Wrist Arteries/Veins Other_______________• Did you have any problems with the anesthesia for any of those surgeries?I have not had problems with anesthesiaNausea and/or Vomiting Muscle Aches Sore ThroatUncontrolled post-operative pain Damaged Teeth Eye PainAwareness or memories of surgery Back Pain HeadacheDifficulty having breathing tube inserted Long time to get back to “normal” Malignant hyperthermiaPseudocholinesterase deficiency Delirium/Confusion Other ______________• Do any blood relatives have problems with anesthesia that you are aware of? No Yes (please explain):F. DENTAL HISTORY• Do you have any of the following? Ihave no dental problemsLoose Teeth Bridges Temporomandibular Joint Disease (TMJ)Chipped Teeth Dentures Caps / VeneersG. GASTROINTESTINAL DISEASE HISTORY• Do you have a history of any of the following liver or intestinal problems? I have no liver or intestinal problemsAcid reflux (GERD) / heartburn GI bleeding / rectal bleeding Pancreatitis Cirrhosis of liverInflammatory bowel disease(Crohn’s disease, ulcerative colitis)Stomach / duodenal ulcer Esophageal varices / vomiting bloodIrritable bowel syndrome Stool incontinence Hiatal herniaProblems swallowing or digesting Diarrhea / Constipation Jaundice Gallstones• When was your last colonoscopy screening? ________________H. HEART DISEASE HISTORYWho is your cardiologist? (If applicable)Name: Phone #:• Do you have a history of any of the following heart or blood vessel problems?I have never had a colonoscopyWhen were youlast seen by him/her?I have no heart or blood vessel problemsHigh blood pressure / hypertension Heart failure (CHF)High cholesterol / HyperlipidemiaCongenital heart diseaseHeart attack / myocardial infarction (MI) (Approximate date:____________) Coronary artery blockagesHeart Surgery or Coronary Stents (Approximate date:______________) Blood clotsAbnormal heart rhythm / Implanted defibrillator (AICD) / Pacemaker Heart valve disease / Heart murmurAneurysm or peripheral vascular diseaseMR 1588 (9/08) of 4