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
 
 
Leg Circulation Surgery
 
 
Mastoidectomy
 
 

Thyroid Removal
 
 
 

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

Caesarean Section
 
 

Heart Valve Replacement
 
 
 

Heart Bypass Surgery
 
 
 
 

IMPORTANT: Please do not use the 'BACK' button on your browser while completing your history forms.
 
Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 608
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.