Medical History Surgery QuestionnairePlease complete & submit this medical questionnaire in preparation for your surgery. Your Personal Information First Name Last Name * Phone Number * Date of Birth * Name of Primary Care Physician Chief Complaint Reason for Surgery * Tubal Reversal Other Current Medications: List all medications or None if Not Applicable * Allergies: List all medication allergies or None if Not Applicable * GYN History What age did your menses begin? * 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Calendar date of last menstrual cycle * What is the time period (in days) between your menstrual cycle? (1st day of last period to 1st day of next period) * Do you have pelvic pain? * No YesDo you have Dyspareunia (pain with intercourse)? * No YesHave you been diagnosed with Pelvic Inflammatory Disease? * No YesDo you have Dysmenorrhea (pelvic pain with menses)? * No YesDo you have a history of Fibroids? * No YesDo you have a history of Anemia? * No YesHave you ever had Chlamydia or Gonorrhea? * No Yes List STD type, year contracted & if you were treated. * OB History Number of pregnancies in lifetime * 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 More than 15 Number of living children * 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 More than 15 Have you ever had an abortion/miscarriage? * No Yes Number of "spontaneous" abortions/miscarriages * 0 1 2 3 4 5 6 7 8 9 10 or more Number of "elective" abortions * 0 1 2 3 4 5 6 7 8 9 10 or more Have you ever had an ectopic "tubal" pregnancy? * No Yes Provide the year and outcome of the ectopic. * Contraceptive method(s) currently used * Date of last PAP * Date of last mammogram Partner History Partner's First and Last Name * Partner's number of children * 0 1 2 3 4 5 6 7 8 9 10 or more Unknown Not Applicable List the ages of each of your partner's children * List any medical conditions your partner has * List any surgeries your partner has had & year performed * List any medications your partner currently takes (include name, dosage & frequency) * Date of semen analysis or N/A if not performed * Patient History List any surgeries you have had and the year performed * List any illnesses or health concerns, past or present * List any injuries in your medical history * Weight (Pounds) * 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 + Height (Feet) * 4 5 6 Height (Inches) * 0 1 2 3 4 5 6 7 8 9 10 11 Family History - Mother Is your mother Living, Deceased or Unknown * Living Deceased Unknown If your mother is deceased, list cause * Family History - Father Is your father Living, Deceased or Unknown * Living Deceased Unknown If your father is deceased, list cause. * Family History - Siblings Number of siblings * 0 1 2 3 4 5 6 7 8 9 10 or more Unknown Number of living siblings * 0 1 2 3 4 5 6 7 8 9 10 or more Unknown Number of deceased siblings * 0 1 2 3 4 5 6 7 8 9 10 or more Unknown Cause(s) of death for any deceased sibling(s) * Family History(Includes: Mother, Father, In-laws, Grandparents, Aunts, Uncles, Siblings, etc.) Answer "None" if no family history. List relationship of anyone in family with a history of diabetes * List relationship of anyone in family with a history of heart disease * List relationship of anyone in family with a history of hypertension * List relationship of anyone in family with a history of ovarian cancer * List relationship of anyone in family with a history of breast cancer * List any other relevant health concern a family member has had & their relationship * Social History Do you use tobacco products? * No Yes List type of tobacco and frequency. * Do you drink/consume alochol? * No Yes List the kind consumed and frequency * Have you ever been involved in any form of domestic violence? * No Yes Please describe. * Do you use any drugs? * No Yes List drug type and frequency. * AcknowledgementBy Submitting: I acknowledge that all information provided is accurate and true. I understand that providing incorrect information could affect my surgical outcome. reCAPTCHA If you are human, leave this field blank.