Surgical Implants Sample Clauses

Surgical Implants. Medical alerts: _ Pregnancy: yes no PAIN SCALE: Rate the severity of your pain by checking a box on the following scale. Signature of Insured/Guardian Date Headache Feet/Hands Cold Unbalanced Mental dullness Depression Fainting Loss of memory Rib pain Blurred vision Dizzy Nervousness Irritability Ears ringing/buzzing Eye strain/pain Double vision Upper back pain Shortness of breath Loss of smell Lower back pain Fear Chest pain Midback pain Confusion Neck pain Pins and needles in hands Pins and needles in arms Pins and needles in legs right/left right/left right/left Broken Bones: (which and when) Medications: (please list all medications and supplements that you currently take) Allergies: (please list all medications that cause allergic reaction) Smoking: Yes No If yes, Packs per Day for years Alcohol Yes No If yes, Number of drinks per week Surgery Date Please indicate with an “X” any medical problems that you currently have or have had in the past. □ NO MEDICAL PROBLEMS - no prior history of any significant medical problems □ asthma □ pulmonary embolism □ respiratory arrest □ COPD □ pneumonia □ sleep apnea □ emphysema □ tuberculosis □ other: □ chest pain / angina □ high blood pressure □ irregular heartbeat, arrhythmia □ heart attack, myocardial infarction □ heart murmur, valve disorder □ peripheral vascular disease □ congestive heart failure □ mitral valve prolapse □ deep vein thrombosis □ other: □ bleeding problems □ stroke or TIA □ xxxxxxxxx’x □ cerebral palsy □ peripheral neuropathy □ MS □ polio □ other: □ osteoarthritis □ gout □ osteomyelitis □ rheumatoid arthritis □ lupus □ ankylosing spondylitis □ other: □ peptic ulcer or stomach ulcer □ diverticulitis □ hepatitis - Type □ acid reflux, GERD □ irritable bowel □ liver disease □ GI bleed □ inflammatory bowel disease □ other: □ urinary tract infection □ kidney problems □ dialysis, kidney failure □ bladder problems □ kidney stones □ other: □ Diabetes x years □ skin disorder □ depression □ thyroid problems □ psoriasis □ anxiety □ sickle cell disease □ any skin ulcer □ alcohol or drug dependency □ high cholesterol or lipids □ tooth abscess, gingivitis □ other: Cancer : any type -- please specify Other medical problems NOT included above (explain)

Surgical Implants. A device or devices which are surgically implanted to form a permanent or long-term part of the body but does not include external prosthesis.

Surgical Implants. Medical alerts: Pregnancy: yes _ no _ Personal Medical History & Review of Systems:

Surgical Implants. Medical alerts: _ Pregnancy: yes no PAIN SCALE: Rate the severity of your pain by checking a box on the following scale. Signature of Insured/Guardian Date Headache Feet/Hands Cold Unbalanced Mental dullness Depression Fainting Loss of memory Rib pain Blurred vision Dizzy Nervousness Irritability Ears ringing/buzzing Eye strain/pain Double vision Upper back pain Shortness of breath Loss of smell Lower back pain Fear Chest pain Midback pain Confusion Neck pain Pins and needles in hands Pins and needles in arms Pins and needles in legs Right/left right/left right/left