PATIENT HEALTH HISTORY

San Diego Office
HM Poole Building
9834 Genesee Avenue, Suite 425
La Jolla, CA 92037
TEL (858) 558-8868
FAX (858) 558-1726

Coronado Office
1001 B Avenue
Suite 112
Coronado, CA 92118

 
  Welcome and thank you for selecting our health care team! We will strive to provide you with the best possible health care services. Please fill out this form completely. If you have any questions or need assistance, please email us—we will be happy to help you.   1. Fill out, print and bring this form in to our office.

2. Or... Submit this form to us online below. 		 
 
Your information is private and secure. No information remains on the computer server and no information is released to any person other than Dr. Wahl's office.
 
PERSONAL INFORMATION:
Patient's First Name:
 Mid. Initial:
Patient's Last Name:
Insurance Company:
Certificate Number:
 
MEDICAL HISTORY - Please explain in detail the answers to the following questions:
 

Have you had a complete physical exam in the last year?

Yes     No
  Month? Year?
  By whom? Don't know
  List all medications and doses taken regularly: None taken
  Medication: Dose: X per day:
  Medication: Dose: X per day:
  Medication: Dose: X per day:
  Medication: Dose: X per day:
 
FAMILY HISTORY:
Do you have any significant family diseases? Yes     No
List Diseases - such as diabetes, heart, etc.
 
SURGICAL HISTORY—Check all that apply:
   SURGERIES     
Have you had any surgeries? Yes     No
If yes, describe type of surgery:
Date of Surgery:
Hospital/City/State:
Check any surgeries listed below that you have had:
Appendectomy? Yes    
Breast Surgery? Yes    
Cesarean Section? Yes    
Cosmetic Surgery? Yes    
D & C? Yes    
Extraction of Teeth? Yes    
Eye Surgery? Yes    
Gallbladder Surgery? Yes    
Heart Surgery? Yes    
Hernia Repair? Yes    
Hemorrhoideotomy? Yes    
Hysterectomy? Yes    
Kidney Surgery? Yes    
Nose Surgery? Yes    
Prostrate/Bladder? Yes    
Skin Surgery? Yes    
Tonsils and Adenoids? Yes    
Tumor Surgery? Yes    
Other Surgery? Yes    
   PROBLEMS DURING SURGERY
Any abnormal bleeding or scarring after surgery?
 Yes     No
have you ever had a problem during surgery? Yes     No
If yes, describe problem and type of surgery:
Date of Surgery:
Hospital/City/State:
 
ANESTHESIA HISTORY - PROBLEMS
Any problems related to anesthesia?
Yes     No
If yes, explain any anesthesia problems:
Has any family member had an
unexpected problem during surgery?
 Yes     No
If yes, please describe problem:
Do any drugs give you an allergic reaction?
 Yes     No
If yes, list drugs that give you an allergic reaction and describe what happens:
 
REVIEW OF SYSTEMS:
   BONE AND JOINT  
Arthritis, muscular or joint problems?
 Yes     No
   CARDIOVASCULAR  
Have you ever been treated for any heart rhythm problem?
 Yes     No
Heart attack or failure?
 Yes     No
Heart valve replacement?
 Yes     No
Recurrent chest pains?
 Yes     No
Heart murmur?
 Yes     No
High blood pressure?
 Yes     No
Mitral valve prolapse?
 Yes     No
Rheumatic fever?
 Yes     No
Congenital heart disease?
 Yes     No
Pace Maker?
 Yes     No
   DENTAL  
Unusual bleeding from gums?
 Yes     No
Do you wear complete or partial dentures?
 Yes     No
   DERMATOLOGIC  
Psoriasis, herpes, skin cancers, rashes?
 Yes     No
   ENDOCRINE  
Do you have hyper or hypo tension?
 Yes     No
Do you have diabetes?
 Yes     No
If yes, medication taken and dosage:
   EYE  

Do you wear glasses or contacts?
 Yes     No

Any visual trouble with one or both eyes?
 Yes     No
Any history of retinal detachment, glaucoma, or ocmeal ulcer?
 Yes     No
Glaucoma?
 Yes     No
Cataracts?
 Yes     No
   EAR - NOSE - THROAT  
Hearing loss, ear surgery?
 Yes     No
Nasal polyps, chronic sinus disease?
 Yes     No
Chronic hoarseness, difficulty swallowing?
 Yes     No

Any other eye-ear-nose-throat problems?
 Yes     No
If yes, explain problem:
   GENITOURINARY
Any difficulties with kidneys, bladder or reproductive system?
 Yes     No
Venereal disease?
 Yes     No
   GYNECOLOGIC
Menstrual irregularities or excessive bleeding?
 Yes     No
   HEMATOLOGIC
A.I.D.S.?
 Yes     No
Anemia?
 Yes     No
Blood transfusion?
 Yes     No

Easy bruisability?
 Yes     No
H.I.V. positive?
 Yes     No
Hepatitis?
 Yes     No
   NEUROPSYCHIATRIC
Frequent headaches?
 Yes     No
Have you ever had a nervous breakdown?
 Yes     No
Have you seen a psychologist or psychiatrist?
 Yes     No
Epilepsy, fainting spells or seizures?
 Yes     No
Depression?
 Yes     No
   RESPIRATORY
Asthma, chronic lung or bronchial condition?
 Yes     No
Tuberculosis or Valley Fever?
 Yes     No
   GENERAL
When you walk up a flight of stairs, do
you stop because of chest pain?
 Yes     No
Do your ankles swell during the day?
 Yes     No
Do you use more than two pillows to sleep at night?
 Yes     No
Have you ever had a tumor or cancer?
 Yes     No
Do you smoke?
 Yes     No
How much do you smoke?
Do you drink alcohol?
 Yes     No
How much alcohol do you drink?
Do you drink more than 6 cups of coffee per day?
 Yes     No
Do you wear any type of prostheses?
 Yes     No
Any illness such as hepatitis, TB, herpes, that may require special sterilization
procedures to protect our staff or other patients?
 Yes     No
Do you have any condition, disease or problem not listed?
 Yes     No
If yes, please describe:

Now that you have completed this form, print out from your computer and bring it into our office.
or
 
Your information is private and secure. No information remains on the computer server and no information is released to any person other than Dr. Wahl's office.
3. Next, please fill out the Patient Registration Form