Greater Erie Surgery Center - Online Heath History Form

SUBMIT YOUR HISTORY

To submit fill out the form below.

Psychological:

Depression/Anxiety/Alzheimers/Bipolar/Claustrophobic:

Metabolic

Diabetic: High Blood Sugar : Hyper /Hypo Thyroid:

Neuro:

CVA/Seizure Disorder /Transient Ischemia: Chronic Migraines/HA:

Back Pain/Neck Pain/Arthritis:

Muscular Weakness:

Upper Extremities Side: Lower Extremities Side:

Pulmonary:

Asthma/COPD/Emphysema: Cough/Dry/Productive:

Sleep Apnea/CPAP:

Cardiac:

Coronary Artery Disease/ Heart Attack/ High Blood Pressure / Congestive Heart Failure /

Mitral Valve Prolapse:

High Cholesterol: Pacemaker/CD/Valve Implant:

GI:

Hiatal Hernia/Gastroesophageal Reflux Disease/ Peptic Ulcer:

Appetite:

GU:

Renal Failure/Dialysis/Chronic Urinary Tract Infection:

Recent Cold/Flu/Upper Respiratory Infection:

Infectious Diagnosis/MRSA/TB/Hepatitis: If Hepatitis list Type:

Blood Thinners/Bleeding Disorders:

Blood Transfusion/Reaction: Date:

Cancer: Type:

Menopause/Hysterectomy/L.M.C.: Date: