History and Intake Form Past Medical History: (please circle all that apply) Anxiety Hepatitis Arthritis Hypertension Artificial joints HIV/AIDS Asthma Hypercholesterolemia Atrial fibrillation Hyperthyroidism Bone Marrow Transplantation Hypothyroidism Breast Cancer Kidney Failure Colon Cancer Leukemia Congestive Heart Failure Lung Cancer COPD Lymphoma Coronary Artery Disease Pacemaker Depression Prostate Cancer Diabetes Radiation Treatment Dementia Seizures End Stage Renal Disease Stroke GERD Valve Replacement Hearing Loss None Heart Attack Other _________________________________________________________________________________________ Past Surgical History: (please circle all that apply) Bladder Removed Kidney Transplant Mastectomy (Right, Left, Bilateral) Ovaries Removed: Endometriosis Lumpectomy (Right, Left, Bilateral) Ovaries Removed: Ovarian Cancer Colectomy: Colon Cancer Resection Prostate Removed: Prostate Cancer Colectomy: Diverticulitis Prostate Biopsy Colectomy: IBD Basal Cell Cancer Surgery Coronary Artery Bypass Squamous Cell Carcinoma Surgery Mechanical Valve Replacement Stents Biological Valve Replacement Melanoma Surgery Heart Transplant Hysterectomy: Fibroids Kidney Removed (Right, Left) Hysterectomy: Uterine Cancer Kidney Stone Removal None Other _________________________________________________________________________________________
History and Intake Form Past Medical History: (please circle all that apply) Anxiety Arthritis Artificial joints Asthma Atrial fibrillation Bone Marrow Transplantation Breast Cancer Colon Cancer Congestive Heart Failure COPD Coronary Artery Disease Depression Diabetes Dementia End Stage Renal Disease GERD Hearing Loss Heart Attack Hepatitis Hypertension HIV/AIDS Hypercholesterolemia Hyperthyroidism Hypothyroidism Kidney Failure Leukemia Lung Cancer Lymphoma Pacemaker Prostate Cancer Radiation Treatment Seizures Stroke Valve Replacement None Other _________________________________________________________________________________________ Past Surgical History: (please circle all that apply) Bladder Removed Mastectomy (Right, Left, Bilateral) Lumpectomy (Right, Left, Bilateral) Colectomy: Colon Cancer Resection Colectomy: Diverticulitis Colectomy: IBD Coronary Artery Bypass Mechanical Valve Replacement Biological Valve Replacement Heart Transplant Kidney Removed (Right, Left) Kidney Stone Removal Kidney Transplant Ovaries Removed: Endometriosis Ovaries Removed: Ovarian Cancer Prostate Removed: Prostate Cancer Prostate Biopsy Basal Cell Cancer Surgery Squamous Cell Carcinoma Surgery Stents Melanoma Surgery Hysterectomy: Fibroids Hysterectomy: Uterine Cancer None Other _________________________________________________________________________________________
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