Common use of Surgical Implants Clause in Contracts

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 Present Complaints (Please circle the appropriate ones) 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 Surgical History: Please list ALL previous surgery and the date on which it was performed: Surgery Date Personal Medical History & Review of Systems: 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 Lungs / Pulmonary – breathing disorders □ asthma □ pulmonary embolism □ respiratory arrest □ COPD □ pneumonia □ sleep apnea □ emphysema □ tuberculosis □ other: Cardiac / Heart and peripheral vascular disease □ 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 Neurologic Disorders □ stroke or TIA □ xxxxxxxxx’x □ cerebral palsy □ peripheral neuropathy □ MS □ polio □ other: Bone & Joint Disorders □ osteoarthritis □ gout □ osteomyelitis □ rheumatoid arthritis □ lupus □ ankylosing spondylitis □ other: Gastrointestinal Disorders □ peptic ulcer or stomach ulcer □ diverticulitis □ hepatitis - Type □ acid reflux, GERD □ irritable bowel □ liver disease □ GI bleed □ inflammatory bowel disease □ other: Genitourinary Disorders □ urinary tract infection □ kidney problems □ dialysis, kidney failure □ bladder problems □ kidney stones □ other: Metabolic & Other Disorders □ 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. 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 Present Complaints (Please circle the appropriate ones) Headache Feet/Hands Cold Unbalanced Mental dullness Depression Neck pain Lower back pain Mid-back pain Upper back pain Fainting Loss of memory Rib pain Blurred Confusion blurred vision Dizzy Nervousness Irritability Ears ringing/buzzing Eye strain/Chest pain Double vision Upper back pain Shortness of breath Loss of smell Lower back pain Fear Chest pain Midback pain Confusion Neck pain Depression 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 Surgical History: Please list ALL previous surgery surgeries and the date on which it was performed: Surgery _ Date Personal Medical History & Review of Systems: 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 Lungs / Pulmonary – breathing disorders Please indicate with an “X” any significant family medical history or problems. □ asthma □ pulmonary embolism □ respiratory arrest □ COPD □ pneumonia tuberculosis □ sleep apnea □ emphysema COPD or Emphysema □ tuberculosis □ otherother lung: Cardiac / Heart and peripheral vascular disease □ 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: irregular heartbeat, arrhythmia □ bleeding problems Neurologic Disorders □ stroke or TIA other heart: □ xxxxxxxxx’x □ cerebral palsy □ peripheral Peripheral neuropathy □ MS or Xxxxxxxxx’x □ polio □ otherother neuro: Bone & Joint Disorders □ osteoarthritis □ Lupus □ gout □ osteomyelitis □ rheumatoid arthritis □ lupus □ ankylosing spondylitis □ otherOther bone & joint: Gastrointestinal Disorders □ peptic ulcer or stomach ulcer □ diverticulitis □ hepatitis - Type □ acid reflux, GERD □ irritable inflammatory bowel disease □ hepatitis - Type □ liver disease □ GI bleed □ inflammatory bowel disease □ otherother GI: Genitourinary Disorders □ urinary tract infection □ kidney problems □ dialysis, kidney failure □ bladder problems diabetes □ kidney stones psoriasis □ other: Metabolic & Other Disorders □ Diabetes x years □ skin disorder □ depression high cholesterol or lipids □ thyroid problems □ psoriasis □ anxiety □ sickle cell disease □ any skin ulcer □ alcohol or drug dependency □ high cholesterol or lipids □ tooth abscess, gingivitis □ other: Cancer Malignant hyperthermia Cancer: any type -- please specify Other medical problems NOT included above (explain)