Capitol City Surgery Center
Medical History
This information is private and will not be shared with any other persons or organizations. It is strictly used by Capitol City Surgery Center in preparation for surgical procedures.
Capitol City Surgery Center is not responsible for any omissions and/or mistakes made in filling out this form.
Patient Information:
*
* LastName:
* FirstName:
* Phone:
* Select your Physician:

Medical Conditions:
Please check all conditions that apply, and add notes as required.
Heart Conditions:
Heart Disease:
Heart Attack:
Irregular Rhythm:
Chest Pain:
Heart Surgery:
Pacemaker/Implanted Defibrillator:
Other/Specify:

Brain Conditions:
Stroke:
Seizures:
Other/Specify:

Mental Conditions:
Mental Illness:
Depression:
Claustrophobia:
Panic Attacks:
Other/Specify:

Circulation Conditions:
High Blood Pressure:
Other/Specify:

Pulmonary Conditions:
Asthma:
Allergies:
Pneumonia/Bronchitis:
Tuberculosis:
COPD:
Emphysema:
Other/Specify:

Liver Conditions:
Hepatitis:
Other/Specify:

Stomach Conditions:
Ulcers:
Reflux:
Indigestion:
Other/Specify:

Kidney/Urinary Conditions:
Prostate drugs:
Other/Specify:

Intestinal Conditions:
IBS:
Other/Specify:

Diabetic Conditions:
Insulin Dependent:
Non-Insulin Dependent:
Other/Specify:

Arthritis:
Rheumatoid:
Osteoarthritis:
Other/Specify:

Thyroid Conditions:
Hypothyroid:
Hyperthyroid:
Other/Specify:

Head/Neck Conditions:
Neck:
TMJ:
Sleep Apnea:
Other/Specify:

Blood Transfusion/ Bleeding Tendencies:
Yes:
Other/Specify:

Recreational Drug Use:
Yes:
Type, Frequency, etc:

Tobacco Use:
Quit:
Smoker:
Other:
Packs/day and # years smoked:

Alchohol Use:
Yes:
Drinks/day/week/month:

Prosthetics/ Implants:
Yes:
Other/Specify:

Medication Allergies:
Yes:
Please list:

Anesthesia Problems (Family history of):
Yes:
Please list(Nausea, vomiting, hard to wake, etc):

Eye Conditions:
Glacoma:
Cataracts:
Please detail (ie. right/left/both):

Oral Problems:
Dentures:
Bridges:
Partials:
Crowns:
Loose/Missing Teeth:
Oral surgery:
Jaw Problems/Pain:
Please list:

* denotes required field