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

OFFICE USE ONLY