ORPO - Physician

PATIENT QUESTIONNAIRE (ADULT) Cont'dPRE-SURGICAL HEALTH HISTORYRegional Surgical Program*ORPO*ORPO104973ARev: Feb. 21/12Page: 3 of 4Do you have or have you had any of the following:Hiatus herniaOngoing heart burn or acid refluxStomach ulcersOther Stomach or bowelproblems:CirrhosisHepatitis type:Yes No Bladder problems: Type: Yes NoYes No Enlarged prostate Yes NoYes No Women: Could you be pregnant? Yes NoIf yes, how many weeks?Yes No Thyroid problem: Type: Yes NoYes No Diabetes - Controlled by:Yes NoInsulin Pills DietYes No Rheumatoid arthritis Yes NoKidney disease. Type:Dialysis: HemoInfection: HIVHepatitis type:PeritonealTBYes No Lupus Yes NoCancer: TypeYes Nochemo radiation Last dose:Yes No Daily painYes NoOther conditions:List the name of any specialistyou've seen.Date oflast visit below to any testyou've had.WhereWhenHeart /cardiacExercise test orDr.treadmillLung/respirologistHolter monitorDr.for 24 hoursBlood/haematologistHeart cath orDr.angiogramNeurologistHeart echo testDr.or heart ultrasoundOther:Heart scan MlBlOther:Pulmonary lungfunction test

PATIENT QUESTIONNAIRE (ADULT) Cont'dPRE-SURGICAL HEALTH HISTORYRegional Surgical ProgramPage: 4 of 4Do you drink alcohol? If yes, how many drinks per day?1 drink is: 5 ounces of wine, 1.5 ounces of hard liquor, 12 ounces of beer.Do you use any recreational drugs?If yes, what drug(s)date last used:YesYesNoNoDo you need help from someone to get dressed or move around your home? Yes NoWill you have someone to help you after you return home? Yes NoDo you often feel sad, blue, upset or hopeless? Yes NoDo you suffer from frequent anxiety feelings and or panic attacks? Yes NoHow would you rate your health?Excellent Good Fair PoorHow sure are you that you can manage at home after surgery? Circle the number.0 1 2 3 4 5 6 7 8 9 10Not sureVery sureDo you take any over the counter or prescribed medicines? Any vitamins? Any herbal?If yes, write below or attach your own list.Medication Dose How often? Medication Dose How often?Do you have cultural or religious beliefs you would like us to know about? If yes,Explain:What is your primary language?Please provide the name and phone number if this form has been filled out by someone otherthan the patient: Name:Phone:I would like you to send my patient information to my e-mail address:Patient Signature:Date: