MRN
PATIENT HISTORY FORM
ACN
Surname
Given Names
Date of birth
Phone No.
Sydney contact phone no.
Mobile No.
Admission Date
Admitting Doctor
2 0
PATIENT HISTORY
(please circle the appropriate answer or tick the appropriate box)
Resp. Endo.
Planned procedure
Diabetes
Controlled by:
Is this admission the result of a past injury?
Specify cause & place
diet
tablet
injection
Bronchitis / asthma / emphysema etc
Specify
Do you use:
nebulisers
puffers
home oxygen
Cardiovascular
MS
GIT
Perf & PUNCH positioning as per previous booklets
Neurology
GIT
General health
Previous Surgery
*
S
A
6
2
Other
R
Y
N
Y
N
Recent cold
N Other lung problems
Y
N
Y
N
N
Chest pain / angina
Y
N
Palpitations / heart murmur /
irregular heart beat / AF
Y
N
Specify
Y
Y
N
Artificial implants / devices / grafts
Coronary artery bypass
Y
N
Coronary / vascular stent
Y
N
Artificial heart valve
Y
N
Pacemaker
Y
N
Gastric ulcer / reflux / hiatus hernia
Y
N
Hepatitis
Y
N
Jaundice
Y
N
Stoma
Y
N
Arthritis
Y
N
Hip / knee replacements
Y
N
Back / neck injury or problems
Y
N
Other implants / devices
Y
N
Fits / faints / funny turns / epilepsy
Y
N
Y
N
Y
N
Y
N
Specify
Stroke / mini stroke / TIA If yes, any residual weakness,
Specify
Specify
Specify
Specify
Speech / swallowing problems
Limb paralysis
right arm
right leg
please specify
Y
N
Previous falls / unsteady on feet
Y
N
Short term memory loss / dementia
Specify
Y
N
Kidney trouble / dialysis / renal impairment
Y
N
Stomas
Specify
Y
N
Bladder problems
urinary incontinence
urgency
Have you ever smoked?
Y
N
If yes, daily amount
If yes,
Do you presently smoke?
Y
N
Do you drink alcohol?
Y
N
Past history of drug dependency
Y
N
Disturbed sleep pattern / sleep apnoea
Y
N
Could you be pregnant?
Y
N
Do you have chronic pain?
Y
N
eg. Coronary artery bypass, brain, liver or
pancreatic surgery, hip replacements,
Y
N
Problems with anaesthetic (self or family)
eg. Malignant hyperthermia
Y
N
Cancer
Date:
Y
N
Y
N
/
/
Site:
Transplants
Polio / meningitis
Specify
NB: you may be asked to provide a family member
or carer to be in attendance during your stay
frequency
pain
Y
N
Date ceased
per day
standard drinks per day
Specify
CPAP used
Specify
Specify
If Yes,
Specify
self
family
Treatment
surgery
Specify
Do you have Creutzfeldt-Jakob Disease (CJD)?
Specify
Have you had Human Pituitary Growth Hormone prior to 1985?
Specify
Have you had neurosurgery prior to 1985?
Specify
New SDSH form V1 May 10
left arm
left leg
chemotherapy
radiotherapy
MR 26AS
M
Low blood sugar
Thyroid problems
Previous deep vein thrombosis / pulmonary embolism /
varicose veins
Specify
*
Y
N
N
PATIENT HISTORY FORM (SDSH)
High blood pressure
Y
Y
Patient ID label
MRN ..................................................................................
Surname ...........................................................................
PATIENT HISTORY FORM
Given Names ...................................................................
(continued)
DOB ..................................................................................
Height & weight details
Height
Dietary Requirements
Weight
cm
Do you have a special diet?
No
kg
Yes (specify)
Prosthetics / Aids / Other
Visual aids
Y
N
Glasses
Contact lenses
Hearing aids
Y
N
Left
Right
Walking aids
Y
N
Specify
Allergies & Sensitivities
Allergies
Eye prosthesis
Please document any known allergies or sensitivities eg. medications, latex plants, tape
Sensitivities
Reaction
Food allergy
Your current
Medications
Prescription Medication
Geranin
Please include tablets, capsules, puffers, nebulisers, patches, insulin, eye drops. Consult your GP or surgeon if you
are unsure of any details about your medications or which medications should be ceased prior to your surgery. Bring to the
hospital all current medication you are taking, in their original individual packaging (ie. not in Webster or Doset packs)
Strength
100mgs
Dose & Frequency
Purposet
one tablet twice a day
If you are taking any non-prescription medication eg. Complementary therapies, natural therapies, herbal preparations or vitamins, please specify
NB: All complementary medicine should be ceased 10 days prior to admission (unless otherwise instructed by your doctor)
Non- Prescription
Medication
Discharge
Planning &
community
support
Strength
Do you live alone?
Dose & Frequency
Yes
No
Purpose
If not, with whom?
Who is your main carer?
Do you receive community services?
Yes
No
If Yes,
Nurses
Home Care
Meal on Wheels
Who will be taking you home and be with you for 24 hours?
Going home
SIGNATURE
PATIENT /
CARER
Name
Relationship
Best contact phone no
Or mobile no.
I have carefully read all the above and I certify that the
information I have given is correct and true to the best of
my ability.
Form completed by:
Signature ..................................................................
Carer ............................................./Sign.
Date ........../............/...................
Patient ........................................../Sign.