Plymouth Family Physicians

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920.893.0526 Fax: 920-893-9409

1000 Eastern Avenue, Plymouth, WI 53073

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Preoperative History & Physical

Please complete this ENTIRE form and bring it with you to your scheduled appointment. This is used to up date your medical history and reduce the risks of complications from surgery and anesthesia.

Thank you for your assistance.

Name*
First Last
Email*
Place of Surgery
Date of Surgery
MM slash DD slash YYYY
Surgeon
Past Medical History (Please list year each issue occurred)
Any unusual childhood illnesses
Past hospitalizations and surgeries
Medical problems
If female, was the date of your last menstrual period?
MM slash DD slash YYYY
Medication Information
Current medications (please list both prescription and non-prescription)
Medication allergies (including type of reaction)
Any history of Latex sensitivity or allergy?
- Yes
- No
Social History
Marital Status
Do you have children?
- Yes
- No
Please list their names and ages:
What is your occupation?
Last year of school completed:
Do you use tobacco?
- Yes
- No
How many packs per day?
Do you use chewing tobacco?
- Yes
- No
How many days per week do you typically drink alcohol?
How many alcohol drinks per week will you usually have?
Any other drug use?
- Yes
- No
Please explain:
Any concerns about sexuality or sexual function?
- Yes
- No
Please explain:
Family History
Please list any illness in your family members including heart disease, stroke, diabetes, cancer, high blood pressure, high cholesterol levels, lung disease, liver or kidney disease, depression or suicide.
Father
Mother
Brothers or Sisters
Children
Grandparents
DO YOU OR ANYONE IN YOUR FAMILY HAVE BAD REACTIONS TO ANESTHESIA?
- Yes
- No
Please Explain
DO YOU OR ANYONE IN YOUR FAMILY HAVE BLEEDING PROBLEMS?
- Yes
- No
Please Explain
Medical Problems
Please check any problems listed below that you have had and note any details including when this occurred.
- Fever, chills, night sweats
- Headaches, head injuries, concussion
- Eye problems (wear contacts or glasses?)
- Loose or capped teeth
- Cold or allergy symptoms
- Ear problems, hearing loss, ringing, pain
- Thyroid problems or x-ray treatment to neck or chest
- Breast masses, breast discharge, breast pain
- Breathing problems, shortness of breath, asthma, bronchitis, pneumonia, emphysema
- High blood pressure, chest pain, palpitations or skipped beats, heart murmur
- Heartburn, ulcers, gallstones, bowel changes, bloody or black bowel movements, abdominal pain
- Kidney or bladder infection, leaking urine, pain with urination, kidney stones
- Muscle pain, joint pain or swelling, broken bones, dislocations, muscle weakness
- Seizure, loss of coordination, tremors, speech problems, memory loss, numbness, tingling
- Skin changes, mole change, skin change, hair loss, psoriasis
- Depression, poor sleeping, appetite problems, panic attacks, suicidal thoughts or attempts
Abnormal bleeding from any site, clotting problems, bruising easily, transfusion
- Yes
- No
If you had a transfusion, what year was this done and why?
Please review your information before submitting.
Plymouth Family Medical Associates use HTTPS encryption on their site to ensure that your medical information is secure.

PLEASE BRING ANY IMMUNIZATION DATES FOR TETANUS, PNEUMOVAX OR RECENT FLU SHOTS IF YOU HAVE THESE RECORDS.

PREOPERATIVE CLEARANCE MAY REQUIRE: LABS, XRAYS OR EKGs. WE WILL ALSO DO OUR BEST TO UPDATE ALL RECOMMENDED HEALTH MAINTENANCE ITEMS AT THE TIME OF THIS VISIT OR, IF TIME IS LIMITED, WE WILL SCHEDULE THESE BEFORE YOU LEAVE.

Plymouth Family Physicians, S.C.

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