Surgery Questionnaire Form - Avera Health

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Patient Health History Questionnaire

Please complete all fields marked with an asterisk (*).

* Required Fields
* First Name
* Last Name
* Birthdate	(format as mm/dd/yyyy)
* Date of Surgery	(format as mm/dd/yyyy)
* Phone Number	(xxx-xxx-xxxx)

1. Any problems with your heart?
* High blood pressure	YesNo	* Heart attack	YesNo
* Chest pain	YesNo	* Murmur or valve problems	YesNo
* Congestive heart failure	YesNo	* Anemia	YesNo
* Irregular heart beat	YesNo	* Bleeding tendency	YesNo
* Blood clots	YesNo	* Implanted defibrillator	YesNo
* Pacemaker	YesNo
Other

2. Any problems with your lungs?
* COPD	YesNo	* Asthma	YesNo
* Reactive airway disease	YesNo	* Recent respiratory infection	YesNo
* Pneumonia	YesNo	* Chronic cough	YesNo
* Sleep apnea	YesNo	* Bronchitis	YesNo
* Shortness of breath	YesNo	* Short of breath when lying flat?	YesNo
* Blood clot in the lung(s)	YesNo	* Short of breath with activity?	YesNo
Other		* Smoking	Yes No
		If yes, how long
		how much

3. Any problems with your urinary/reproductive systems?
* Kidney failure	YesNo	* Kidney disease	YesNo
* Kidney stones	YesNo	* Dialysis	YesNo
* Urinary infections	YesNo	Incontinence	YesNo
* Sexually transmitted diseases	YesNo	Menstrual problems	YesNo
Last menstrual period		Pregnant due date
Post menopausal	YesNo
Other

4. Any problems with your metabolic system?
* Diabetes	Yes No	* Thyroid problems	YesNo
If so, insulin? or	YesNo	* Glaucoma	YesNo
* Oral Medications	YesNo	* Steroid use	Yes No
* Diet Controlled Diabetes	YesNo	If so, when?
Other		Name of Medication

5. Any problems with your musculoskeletal/neuro systems?
* Stroke	Yes No	If so, weakness?	YesNo
* Epilepsy	YesNo	* Seizures	YesNo
* MS	YesNo	* Arthritis	YesNo
* Migraines	YesNo	* Cerebral Palsy	YesNo
* Nerve damage	YesNo	* Muscle weakness	YesNo
Other

6. Any problems with coping?
* Anxiety	YesNo	* Depression	YesNo
* Dementia/Alzheimers	YesNo	* Chemical dependency	YesNo
Other

7. Any problems with your GI system?
* Hiatal hernia	YesNo	* Reflux disease	YesNo
* Peptic ulcers	YesNo	* GI bleed	YesNo
* Ostomy	YesNo	* Jaundice	YesNo
* Cirrhosis	YesNo	* Bowel incontinence	YesNo
* Constipation	YesNo
Other

8. Any problems with your protective mechanism?
* Cancer	Yes No	If so, where?
* Skin disorders	YesNo	* AIDS	YesNo
* HIV positive	YesNo	* Tuberculosis	YesNo
* Hepatitis	YesNo	* Low grade fever	YesNo
* Extreme fatigue	YesNo	* Night sweats	YesNo
* Swollen glands	YesNo	* Productive cough	YesNo
* Bloody sputum	YesNo	* Weight loss	YesNo
* Loss of appetite	YesNo
Other
* Do you drink caffeine	YesNo	* Denture	YesNo
* Tobacco	YesNo	* Partials	YesNo
* Alcohol	YesNo	* Chipped teeth	YesNo
* Street drugs	YesNo	* Loose teeth	YesNo
* Hearing problems	YesNo	* Piercings	YesNo
* Hearing aides	YesNo	Other
* Eyeglasses/contacts	YesNo

9. Surgical History
Please list any operations you have had in the past

10. Family History
* Diabetes	Yes No	If so, who
* Cancer	Yes No	If so, who
* Cardiac disease	Yes No	If so, who
* Chemical dependency	Yes No	If so, who
* Psychiatric disorders	Yes No	If so, who
Medications and dose
Allergies

Important Contact Information:

General
605-622-5000

Billing
605-622-5250

Gift Shop
605-622-5259

Pastoral Care
605-668-8000

Foundation
605-622-5887