Arrant Surgical
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Name
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First
Last
Sex
Male
Female
Other
Height
Weight
Address
City
State
Zip Code
Email Address
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Primary Medical Doctor
Referring Surgeon
Chronic Medical Conditions
No Medical Problems
Diabetes
Heart Disease
Heart Attack
Atrial Fibrillation
High Blood Pressure
Blood Clots (DVT/Pulmonary Embolus)
Cancer
Stroke
Thyroid Problems
Depression
Anxiety
Constipation
Acid Reflux
Stomach Ulcer
Diverticulitis
Kidney Problems
Skin Condition
Asthma
COPD
Sleep Apnea
Other Medical Conditions Not Listed Above or Description of Type of Cancer/Heart Disease/Kidney Problems/etc.
All Surgeries with Date (i.e. Appendectomy - 6/2012)
Mother's History
Living
Deceased
Mother's Age & Medical Problems
Fathers History
Living
Deceased
Father's Age & Medical Problems
Sisters: Number, Age, Medical Problems (i.e. 2 Sisters Age 34 - Diabetes; Age 45 - Heart Attack)
Brothers: Number, Age, Medical Problems (i.e. 1 Brother Age 55 - High Blood Pressure & Prostate Cancer)
Occupation
Employment Status
Employed: Full Time
Employed: Part Time
Unemployed
Diasabled
Marital Status
Single
Married
Seperated
Divorced
Widowed
# of Children
Tobacco
Never Smoked
1/2 Packs Per Day
1 Pack Per Day
2 Packs Per Day
3 Packs Per Day
Previous Smoker
Cigars
If Previous Smoker Date Quit and Amount Previously Smoked (i.e. Quit in 2012 with a 1 Pack Per Day History)
Alcohol: Amount, Type, Frequency (i.e. 2 Glasses of Wine Daily)
Drug Use (Current or Previous)
Marijuana
Cocaine
Heroin
Medications, Dosages, & How Taken (i.e. Lasix 20mg twice a day)
Allergies & Reaction (i.e PCN - Rash)
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