Surgical History
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Robert F. Thompson M.D.
Mark S. Walton M.D.
Steven F Ellis M.D.
Mitchell J. Challis M.D.
Carson Williams M.D.
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Provider Name
Patient Information
*
Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.
Birth Month
January
February
March
April
May
June
July
August
September
October
November
December
Birth Day
1
2
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5
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Birth Year
2021
2020
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2014
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1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
* Required Information
Surgical History
Please mark all surgeries you have had
I have had no surgeries
Anal Fissure Repair
Hemorrhoidectomy
Sinus Surgery
Ulcer Surgery
Appendectomy
Low Back Disc Surgery
Tonsillectomy
Vasectomy
Deviated Nose Septum
Neck Disc Surgery
Tubal Ligation
Prostate Surgery
TURP
Removal
Gallbladder Surgery
Open
Laparoscopic
Colon Polyp Removal
Open
Colonoscopy
Colon Removal
Partial
Complete
Hysterectomy (due to cancer)
Partial
Complete
Hysterectomy (not due to cancer)
Partial
Complete
Spinal Fusion
Neck
Lower Back
Spinal Decompression
Neck
Lower Back
Dilation and Curettage (D&C)
Single
Multiple
Lung Surgery
Left
Right
Both
Kidney Removal
Left
Right
Both
Cataract Surgery
Left
Right
Both
Breast Cancer Lump Removal
Left
Right
Both
Mastectomy
Left
Right
Both
Breast Reconstruction
Left
Right
Both
Breast Reduction
Left
Right
Both
Ovary Removal
Left
Right
Both
Carpal Tunnel Surgery
Left
Right
Both
Rotator Cuff Repair
Left
Right
Both
Arthroscopic Shoulder Surgery
Left
Right
Both
Hip Fracture & Surgery
Left
Right
Both
Total Hip Replacement
Left
Right
Both
Total Knee Replacement
Left
Right
Both
Arthroscopic Knee Surgery
Left
Right
Both
Foot Surgery
Left
Right
Both
Varicose Vein Procedure
Left
Right
Both
Mastoidectomy
Left
Right
Both
Thyroid Removal
Left
Right
Total
Partial
Breast Biopsy
Left
Right
Both
Multiple times
Carotid Artery Surgery
Left
Right
Both
Multiple times
Open Inguinal Hernia Surgery
Left
Right
Both
Multiple times
Laparoscopic Inguinal Hernia Surgery
Left
Right
Both
Multiple times
Caesarean Section
1
2
3 or more
Heart Valve Replacement
Mitral
Aortic
Tricuspid
Unknown Valve
Heart Bypass Surgery
1 vessel
2 vessels
3 vessels
4 or more vessels
Unknown number of vessels
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Oklahoma City, OK 73189
Form Number 60
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