Patient History Form

This form is strictly confidential.

Please complete the entire form and click on the "Submit" button when you are ready to send the information. Additional information and records may be faxed to 570-821-1108 .

If you have any questions please call 570-821-1100.

Patient Information

* denotes required field
* Name:
Birthdate:
Address:
Telephone Number:
Fax Number:
Email Address:

Describe Symptoms:

(Include when symptoms started, how they have progressed, and what you have done to relieve them.)

Pain Description:

Location:

Where does it radiate: (spread to another location)

Severity: (1 least, 10 worst)

1         6
2         7
3         8
4         9
5         10  

Character:

Does your pain come in waves or is it constant?

My pain comes in waves
My pain is constant

What makes it better?

What makes it worse?

Other Medical Problems:

(Be thorough, list dates of onset)

Previous Surgery:

(List dates.)

Medication Allergies:

(Include reaction experienced)

Medications:

(Include doses)

Social History:

Do you smoke: yes        no
How many packs per day        
For how many years years?        

Do you use alcohol? yes        no
Drinks per week/month
I drink approximately drinks perWeek Month

Married: yes        no
Spouse's Name:       

Children: yes        none

Names/Ages of Children:

Career:

Family Medical History:

Illness in mother:

Illness in father:

Other:

Review of Symptoms:

(Check all that you experience, and elaborate below. Add any other symptoms you experience.)

Chest pain palpitations heaviness on chest
shortness of breath blood in urine or stool or vomit diarrhea
constipation difficulty or pain urinating pain in calves when walking
slurred speech weakness on one side of body fever
sweats chills

* A surgeon will review this form and a preliminary evaluation will be made. You will then be contacted by phone, mail or email.

* If you are felt to possibly be a candidate for surgery, your complete medical history will be reviewed including:

- Operative reports of all previous operations
- Previous tests (include x-rays, CT scans, endoscopy reports, etc.)
- Recent laboratory results
- Any letters from your physicians
- A copy of the most recent complete history and physical prepared by a physician

It is a good idea to begin gathering these documents, and preparing to forward them to our office.
* For additional information or questions, call 570-821-1100.

*

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