Hess Orthopaedic Center and Sports Medicine, PLC

    Medical History

    Past Medical History: Have you ever had any of the following? Check all that apply and provide explanation:

    Cancer
    AIDS/HIV
    Gout
    Stroke
    Diabetes
    Malignant Hyperthermia
    Neurological Disease
    Autoimmune Disorder
    High Blood Pressure
    Circulation Problems
    Liver Disease/Hepatitis
    Blood Clots
    Heart Disease
    Kidney Disease
    Blood Transfusions
    Thyroid Disease
    Lung Disease
    Rheumatoid Arthritis
    Anxiety/Depression
    Bleeding Disorder
    Stomach Ulcer/ Heartburn
    Major Infection
    Asthma
    Other

    Have you ever had a reaction to anesthesia? NOYES

    Yes, please explain:

    Are you allergic to latex? NOYES

    Yes, please explain:

    Surgical History
    Social History
    Rheumatoid ArthritisDiabetesHeart DiseaseClotting ProblemsMalignant Hyperthermia
    Allergies

    Medications: Please include all medications, including vitamins, herbal and over the counter

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