Past Surgery Type of Surgery Yes No Institution/City Year(s) of Surgery Surgery Performed Knee arthroplasty Coronary angioplasty/stent Excision of disc in the spine Fusion of spine bones (vertebrae) Hip replacement Gall bladder removal Type of Surgery Yes No Institution/City Year(s) of Surgery Surgery Performed Colon removal (partial or total) Hysterectomy Ovaries removed Tubes tied Vasectomy (men) Circumcision (men) Removal of adhesions in abdomen Fracture of hip, thigh, lower leg bones Coronary artery bypass graft (CABG) Organ transplant Specify organ: List Other Surgeries:
Past Surgery Type of Surgery Yes No Institution/City Surgery Performed Year(s) of Surgery Knee arthroplasty Coronary angioplasty/stent Excision of disc in the spine Fusion of spine bones (vertebrae) Hip replacement Gall bladder removal Type of Surgery Yes No Institution/City Surgery Performed Year(s) of Surgery Colon removal (partial or total) Hysterectomy Ovaries removed Tubes tied Vasectomy (men) Circumcision (men) Removal of adhesions in abdomen Fracture of hip, thigh, lower leg bones Coronary artery bypass graft (CABG) Organ transplant Specify organ: List Other Surgeries:
F2764_Past_and_Current_Illnesses.docx