Patient History Form
This form is strictly confidential.
Please complete the entire form and click on the "Submit" button when you are ready to send the information. Additional information and records may be faxed to 570-821-1108 .
If you have any questions please call 570-821-1100.
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Patient Information
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Describe Symptoms:
(Include when symptoms started, how they have progressed, and what you have done to relieve them.)
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Pain Description:
Location:
Where does it radiate: (spread to another location)
Severity: (1 least, 10 worst)
1 6
2 7
3 8
4 9
5 10
Character:
Does your pain come in waves or is it constant?
My pain comes in waves
My pain is constant
What makes it better?
What makes it worse?
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Other Medical Problems:(Be thorough, list dates of onset)
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Previous Surgery:(List dates.)
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Medication Allergies:
(Include reaction experienced)
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Medications:
(Include doses)
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Social History:
Do you smoke: yes no
How many packs per day
For how many years years?
Do you use alcohol? yes no
Drinks per week/month
I drink approximately drinks perWeek Month
Married: yes no
Spouse's Name:
Children: yes none
Names/Ages of Children:
Career:
Family Medical History:
Illness in mother:
Illness in father:
Other:
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Review of Symptoms:
(Check all that you experience, and elaborate below. Add any other symptoms you experience.)
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* A surgeon will review this form and a preliminary evaluation will be made. You will then be contacted by phone, mail or email.
* If you are felt to possibly be a candidate for surgery, your complete medical history will be reviewed including:
- Operative reports of all previous operations
- Previous tests (include x-rays, CT scans, endoscopy reports, etc.)
- Recent laboratory results
- Any letters from your physicians
- A copy of the most recent complete history and physical prepared by a physician
It is a good idea to begin gathering these documents, and preparing to forward them to our office.
* For additional information or questions, call 570-821-1100.
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