OSF MEDICAL GROUP GENERAL SURGERY Please complete all forms

TRENT D. PROEHL, M.D., F.A.C.S. before your appointment.

JAY H. WOODLAND, M.D. Make sure to bring all
medications with you.

PATIENT HISTORY FORM

MEDICAL HISTORY

Name Date of Birth

Reason for Seeking Medical Attention
Current Illnesses/Medical Conditions:
______________________________ ______________________________ ______________________________
______________________________ ______________________________ ______________________________
______________________________ ______________________________ ______________________________
List all physicians you are currently seeing: Last visit? City/State/Phone
_____________________________________________ _____________ __________________________
_____________________________________________ _____________ __________________________
_____________________________________________ _____________ __________________________
_____________________________________________ _____________ __________________________
Previous Surgeries/Hospitalizations/Serious Illnesses What year? Hosp./City/State
________________________________________________ ___________ _________________________
________________________________________________ ___________ _________________________
________________________________________________ ___________ _________________________
________________________________________________ ___________ _________________________
________________________________________________ ___________ _________________________
________________________________________________ ___________ _________________________
SOCIAL HISTORY
Employment Status: __Employed __Self-Employed __Retired __Unemployed __Disabled ___ Student
Employer and occupation: __________________________________________________________________
Where do you currently reside? ___ Independently ___ Assisted Living Facility ___ Nursing Home
Marital Status: __Single __Married __Separated __Divorced __Widowed
Use of Alcohol:
Current ___No ___Yes if Yes, number of drinks per week ______________________
Past ___No ___Yes if Yes, number of drinks per week ______________________
Use of Tobacco:
Current ___No ___Yes if Yes, number of packs per day _____ Number of years_____
Past ___No ___Yes if Yes, when did you quit? ______________________
Do you use illegal/street drugs? Yes No If so, what do you use?
Do you have a religious affiliation that would affect decisions about your care? Yes No
If yes, please explain
Do you have a: Living Will Healthcare Power of Attorney Do not Resuscitate Order None
FAMILY MEDICAL HISTORY
Age Diseases If deceased, cause of death
Father ______ _________________________________ __________________________
Mother ______ _________________________________ __________________________
Siblings ______ _________________________________ __________________________
______ _________________________________ __________________________
______ _________________________________ __________________________
Spouse ______ _________________________________ __________________________
Children ______ _________________________________ __________________________
______ _________________________________ __________________________
______ _________________________________ __________________________
Patient History Form Page 2

Name Date of Birth

FOR WOMEN ONLY
At what age did you begin menstruation?
What was the date of your last menstrual period?
How many times have you been pregnant?
How many children do you have?
How old were you at the birth of your first child? Did you ever breastfeed?
Do you still have menstrual periods? If not, at what age did you stop?
Do you use birth control or hormone therapy? If so, please list the type
Is there a family history of breast cancer?
If over the age of 35, when was your last mammogram?
MEDICATIONS
Do you have any allergies to medications? Yes ____ No____
Please List all Medication allergies and reactions: _______________________________________________
_______________________________________________________________________________________
Are you allergic to Latex, rubber gloves, rubber bands, or balloons? Yes ____ No____
Do you require antibiotics before surgery or dental procedures? Yes ____ No____

Please list your current medications, vitamins, and herbal supplements (or give receptionist a printed list to copy)
Medication Reason you take Dosage&Times per day Prescribing Doctor

Revised: 03/01/10
C:\Documents and Settings\mcvujovich\Local Settings\Temporary Internet Files\OLK633\PATIENT HISTORY FORM.doc
Patient History Form Page 3

Name Date of Birth

Patient Medical History & Review of Systems
Please indicate any personal history below, past or present
Constitutional Systems Gastrointestinal Psychiatric
Recent weight change ____No ___Yes Abdominal Pain ___No ___Yes Memory Loss or confusion ___No ___Yes
Loss / Gain # of pounds ________ Esophageal Varices ___No ___Yes Nervousness ___No ___Yes
Fever ___No ___Yes Nausea or vomiting ___No ___Yes Depression ___No ___Yes
Eye disease or cataracts ___No ___Yes Frequent diarrhea ___No ___Yes Insomnia ___No ___Yes
Wear glasses/contact lenses ___No ___Yes Change in bowel movement ___No ___Yes Neurological
Blurred or double vision ___No ___Yes Painful bowel movements Frequent or recurring headaches ___No ___Yes
Glaucoma ___No ___Yes or constipation ___No ___Yes Light headed or dizzy ___No ___Yes
Ears/Nose/Mouth/Throat rectal bleeding or Convulsions or seizures ___No ___Yes
Hearing loss or ringing ___No ___Yes blood in stool ___No ___Yes Numbness/tingling sensation ___No ___Yes
Chronic sinus problems ___No ___Yes Stomach ulcer ___No ___Yes Tremors ___No ___Yes
Nose bleeds ___No ___Yes Vomiting blood ___No ___Yes Paralysis ___No ___Yes
Sore throat or voice change ___No ___Yes History of liver disease ___No ___Yes Head injury ___No ___Yes
Cardiovascular Jaundice ___No ___Yes Stroke (RIND or TIA) ___No ___Yes
Heart murmur ___No ___Yes Hepatitis ___No ___Yes Migraine headaches ___No ___Yes
Mitral valve prolapse ___No ___Yes Hemorrhoids ___No ___Yes Brain tumor ___No ___Yes
Rheumatic fever ___No ___Yes Date of last colonoscopy _____________ Endocrine
High or low blood pressure ___No ___Yes Genitourinary Prescription steroid use ___No ___Yes
On blood pressure medication ___No ___Yes frequent urination ___No ___Yes Glandular or hormone problems ___No ___Yes
Chest pain or angina pectoris burning or painful urination ___No ___Yes Excessive thirst or urination ___No ___Yes
In the last 30 days ___No ___Yes Blood in urine ___No ___Yes Heat or cold intolerance ___No ___Yes
Palpitation ___No ___Yes Change in force of stream Diabetes ___No ___Yes
Congestive Heart Failure ___No ___Yes when urinating ___No ___Yes on diabetic medication or insulin?
Pacemaker / AICD ___No ___Yes Incontinence or dribbling ___No ___Yes Thyroid disease ___No ___Yes
Irregular pulse ___No ___Yes Kidney stones ___No ___Yes Kidney disease ___No ___Yes
History of heart attack ___No ___Yes Males – testicle pain ___No ___Yes Kidney failure ___No ___Yes
When? __________________ Males – Date of last PSA? ____________ Hemo Dialysis or CAPD ___No ___Yes
Swelling of feet, ankles or hands ___No ___Yes Females – Date of LMP ____________ Hematologic/Lymphatic
Heart disease ___No ___Yes Females - Hysterectomy or tubal ligation? Slow to heal after cuts ___No ___Yes
Coronary angiogram ___No ___Yes Musculoskeletal Bleeding or bruising tendency ___No ___Yes
When? _________________ Joint pain ___No ___Yes Anemia ___No ___Yes
Heart surgery ___No ___Yes Weakness of muscles/joints___No ___Yes Phlebitis or blood clots in legs ___No ___Yes
When? _________________ Muscle pain or cramps ___No ___Yes Past transfusion-blood/plasma ___No ___Yes
Peripheral Vascular Disease ___No ___Yes Back pain ___No ___Yes Enlarged glands ___No ___Yes
Respiratory Cold extremities ___No ___Yes Cancer ___No ___Yes
Chronic or frequent coughs ___No ___Yes How far can you walk without pain? ______ Chemo or radiation ___No ___Yes
Emphysema or COPD ___No ___Yes Pain while at rest ___No ___Yes HIV+ ___No ___Yes
Asthma ___No ___Yes Arthritis ___No ___Yes
Bronchitis ___No ___Yes Hernia ___No ___Yes Date & location of most recent bloodwork
Tuberculosis or positive TB test ___No ___Yes Integumentary (skin, breast) ___________________________________
Shortness of breath Rash or itching ___No ___Yes
While walking or lying flat ___No ___Yes Change in skin color ___No ___Yes Date & location of most recent EKG
Wheezing ___No ___Yes varicose veins ___No ___Yes ____________________________________
Pneumonia ___No ___Yes Breast pain ___No ___Yes
Spitting up blood ___No ___Yes Breast lump ___No ___Yes Date & location of most recent chest X-ray
Sleep apnea ___No ___Yes Breast discharge ___No ___Yes ____________________________________
Date of last mammo? _______________
Authorization and Release
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can
be dangerous to my health. It is my responsibility to inform the doctor’s office of any changes in my medical status.
___________________________________________________________ ______________________
Signature of patient (or legal representative and relationship) Date
Revised: 03/01/10
C:\Documents and Settings\mcvujovich\Local Settings\Temporary Internet Files\OLK633\PATIENT HISTORY FORM.doc