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 ReversalOther 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? * 910111213141516171819202122 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 * 0123456789101112131415More than 15 Number of living children * 0123456789101112131415More than 15 Have you ever had an abortion/miscarriage? * NoYes Number of "spontaneous" abortions/miscarriages * 012345678910 or more Number of "elective" abortions * 012345678910 or more Have you ever had an ectopic "tubal" pregnancy? * NoYes 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 * 012345678910 or moreUnknownNot 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) * 90919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250251252253254255256257258259260261262263264265266267268269270271272273274275276277278279280281282283284285286287288289290291292293294295296297298299300301302303304305306307308309310311312313314315316317318319320321322323324325326327328329330331332333334335336337338339340341342343344345346347348349350351352353354355356357358359360361362363364365366367368369370371372373374375376377378379380381382383384385386387388389390391392393394395396397398399400 + Height (Feet) * 456 Height (Inches) * 01234567891011 Family History - Mother Is your mother Living, Deceased or Unknown * LivingDeceasedUnknown If your mother is deceased, list cause * Family History - Father Is your father Living, Deceased or Unknown * LivingDeceasedUnknown If your father is deceased, list cause. * Family History - Siblings Number of siblings * 012345678910 or moreUnknown Number of living siblings * 012345678910 or moreUnknown Number of deceased siblings * 012345678910 or moreUnknown 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? * NoYes List type of tobacco and frequency. * Do you drink/consume alochol? * NoYes List the kind consumed and frequency * Have you ever been involved in any form of domestic violence? * NoYes Please describe. * Do you use any drugs? * NoYes 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.