Patient Information (Full Legal Name)
 
 
 
 
 
 
 
 
 
 
 

Please mark all surgeries you have had

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Prostate Surgery
 
 
 
 
Gallbladder Surgery
 
 
 
 
Colon Polyp Removal
 
 
 
 
Colon Removal
 
 
 
 
Hysterectomy (due to cancer)
 
 
 
 
Hysterectomy (not due to cancer)
 
 
 
 
Spinal Fusion
 
 
 
 
Spinal Decompression
 
 
 
 
Dilation and Curettage (D&C)
 
 

 
Lung Surgery
 
 
 
 
 
Kidney Removal
 
 
 
 
 
Cataract Surgery
 
 
 
 
 
Breast Cancer Lump Removal
 
 
 
 
 
Mastectomy
 
 
 
 
 
Breast Reconstruction
 
 
 
 
 
Breast Reduction
 
 
 
 
 
Ovary Removal
 
 
 
 
 
Carpal Tunnel Surgery
 
 
 
 
 
Rotator Cuff Repair
 
 
 
 
 
Arthroscopic Shoulder Surgery
 
 
 
 
 
Hip Fracture & Surgery
 
 
 
 
 
Total Hip Replacement
 
 
 
 
 
Total Knee Replacement
 
 
 
 
 
Arthroscopic Knee Surgery
 
 
 
 
 
Foot Surgery
 
 
 
 
 
Varicose Vein Procedure
 
 
 
 
 
Mastoidectomy
 
 
 

 
Thyroid Removal
 
 
 
 

 
Breast Biopsy
 
 
 
 
 
 
Carotid Artery Surgery
 
 
 
 
 
 
Open Inguinal Hernia Surgery
 
 
 
 
 
 
Laparoscopic Inguinal Hernia Surgery
 
 
 
 

 
Caesarean Section
 
 
 

 
Heart Valve Replacement
 
 
 

 
Heart Bypass Surgery
 
 
 
 
 
 

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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 625
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