ࡱ>  Q+bjbjupup 8"3\ \ 8H(lllNHPHPHPHPHPHPH$JwM~tHlJJ"lltHH$$$lG$lNH$$6BE D*-B RCGH0HCM M8EMEll$llllltHtH",lllHllllMlllllllll\ |: Dear Patient, Welcome to the UCSF Plastic and Reconstructive Surgery Practice. Our goal is to provide a comprehensive evaluation of your surgical problem. During your visit, we will review your medical history, you will undergo a physical exam, and your x-rays will be reviewed. Our health care team consists of medical students, nurse practitioners, and surgical residents under the supervision of your surgeon. Depending on the complexity of your problem, anticipate your visit may last several hours. To prepare for your visit, please obtain copies of all reports relevant to your surgical problem and bring them with you. Examples would be reports of upper endoscopies, pathology, CT scans, laboratory blood tests, barium swallows, and so on. If you have had any x-rays, have your hospital put the images on a CD-ROM and bring it. We need to look at the images, not just the reports. We strive to be detail-oriented and thorough. Your answers here will become part of the UCSF medical record and will be confidential. Legal First Name: Height: Last Name: Weight: Date of Birth: BMI (Body Mass Index):  Can you tell us the names of the doctor who referred you here, your primary care doctor, and any other doctor from whom you are receiving care? Doctor who sent you to see us: ______________________________ City: ___________________ Primary care doctor: ______________________________________ City: ___________________ Additional doctor: _________________________________________ City: ___________________ Additional doctor: _________________________________________ City: ___________________ What is the reason for your visit?  ALLERGIC REACTIONS TO MEDICATIONS Have you ever had a reaction to any of the following: YES NO Latex YES NO Iodine YES NO Intravenous contrast agent (used in CT scans) Are you allergic to any medications? If so, list the medication and the reaction that you had: MEDICATION REACTION (circle all that apply) anaphylaxis/shock rash itching nausea/vomiting short-of-breath other: anaphylaxis/shock rash itching nausea/vomiting short-of-breath other: anaphylaxis/shock rash itching nausea/vomiting short-of-breath other: anaphylaxis/shock rash itching nausea/vomiting short-of-breath other: anaphylaxis/shock rash itching nausea/vomiting short-of-breath other: anaphylaxis/shock rash itching nausea/vomiting short-of-breath other: anaphylaxis/shock rash itching nausea/vomiting short-of-breath other: anaphylaxis/shock rash itching nausea/vomiting short-of-breath other: anaphylaxis/shock rash itching nausea/vomiting short-of-breath other: anaphylaxis/shock rash itching nausea/vomiting short-of-breath other: anaphylaxis/shock rash itching nausea/vomiting short-of-breath other: anaphylaxis/shock rash itching nausea/vomiting short-of-breath other: anaphylaxis/shock rash itching nausea/vomiting short-of-breath other: anaphylaxis/shock rash itching nausea/vomiting short-of-breath other:  MEDICAL HISTORY Please circle any illnesses you have now or in the past. give us detail here: Seasonal allergies (hay fever) Anemia Anxiety Arthritis Asthma Bleeding disorders Blood disorder Blood transfusion in the past Cancer (list types) Congestive Heart Failure Clotting disorder Chronic bronchitis or emphysema Depression Diabetes mellitus Gastroesophageal reflux (heartburn) Glaucoma Heart disease HIV/AIDS Hypertension Intestinal disease Kidney disease Liver disease Myocardial infarction Nerve / muscle disease Osteoporosis Seizures Sinus disorder Skin disease Stroke Substance abuse Thyroid disease Ulcers OTHER: Have you ever been hospitalized? If yes, list the date(s) and reasons. SURGICAL HISTORY Please circle any operations you have had. Year performed Appendectomy Bariatric/ Gastric Bypass Brain surgery Breast surgery Coronary artery bypass surgery Cholecystectomy (gallbladder removal) Colon surgery Cosmetic surgery Cesarian section Eye surgery Fracture surgery Hernia repair Hysterectomy (uterus removal) Joint replacement Prostate surgery Small intestine surgery Spine surgery Tubal ligation Valve replacement Vasectomy OTHER: FAMILY HISTORY Mark an X in the box if any of relative of yours had one of these diseases: Alcoholism Lou Gehrigs Alzeihmeris Arthiritis Asthma Bleeding disorder Breast cancer Cancer Colon Cancer Depression Diabetes Drug abuse Early death Heart disease Hyperlipidemia Hypertension Kidney disease Liver disease Mental illness Osteoporosis Stroke Thyroid disease Tuberculosis Vision loss Mother Father Sister Brother Son Mat Aunt Mat Uncle Pat Aunt Pat Uncle Mat GM Mat GF Pat GM Pat GF Cousin HABITS Are you a (circle one): current smoker former smoker never smoker passive smoker How many packs per day do you smoke, on average? _________________________ How many years have you smoked? ____________________ Do you drink alcohol? YES NO If yes, what is your average number of: glasses of wine per week:______ cans of beer per week: ________ shots of liquor per week: _______ Do you use drugs recreationally now? YES NO If yes, check the drugs you use: ( amphetamines ( amyl nitrate ( anabolic steroid ( barbituates ( benzodiazepines ( crack cocaine ( cocaine ( codeine ( fentanyl ( GHB ( hydrocodone ( hydromorphone ( ketamine ( marijuana ( MDMA ( methamphetamine ( methaqualone ( methylphenidate ( morphine ( nitrous oxide ( opium ( oxycontin ( PCP ( psilocybin ( solvent ( inhalants ( IV drugs ( other: REVIEW OF SYSTEMS Have you experienced any of the following symptoms in the past 3 months? Symptom Comments GENERAL YES NO fevers YES NO chills YES NO weight loss YES NO malaise or fatigue YES NO sweating YES NO weakness SKIN YES NO rash YES NO itching HEAD YES NO headaches YES NO hearing loss YES NO tinnitus YES NO ear pain YES NO ear discharge YES NO nosebleeds YES NO congestion YES NO stridor (groan when you breathe) YES NO sore throat EYES YES NO blurred vision YES NO double vision YES NO irritation with lights (photophobia) YES NO eye pain YES NO eye discharge YES NO eye redness CARDIOVASC YES NO chest pain YES NO palpitations (fluttering in the chest) YES NO orthopnea (difficulty breathing while flat in bed) YES NO claudication (pain in legs with exercise) YES NO leg / ankle swelling YES NO difficulty breathing during sleep LUNGS YES NO cough YES NO hemoptysis (coughing up blood) YES NO sputum production (coughing up phlegm) YES NO shortness of breath YES NO wheezing ABDOMEN YES NO heartburn YES NO nausea YES NO vomiting YES NO abdominal pain YES NO diarrhea YES NO constipation YES NO bright red blood in stool YES NO melena (dark, tar like stools from old blood) URINARY YES NO dysuria (burning when you pee) YES NO urgency (need to pee quickly, cant barely hold it) YES NO frequency (need to pee often) YES NO hematuria (blood in the urine) YES NO flank pain MUSCLES YES NO myalgias (crampy muscle pain) YES NO neck pain YES NO back pain YES NO joint pain YES NO falls BLOOD YES NO easy bruising or easy bleeding YES NO seasonal allergies YES NO polydipsia (always thirsty) NEURO YES NO dizzyness YES NO tingling YES NO tremor YES NO sensory change YES NO speech change YES NO focal weakness YES NO seizures YES NO loss of consciousness PSYCHIATRIC YES NO depression YES NO suicidal ideas YES NO substance abuse YES NO hallucinations YES NO nervous / anxious YES NO insomnia YES NO memory loss      Preferred First Name: Last Name   EMBED MSPhotoEd.3  Plastic and Reconstructive Surgery 350 Parnassus Avenue, Ste 509 San Francisco, CA 94143 (415) 353-4201 400 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