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