Patient History

First Name Last Name

SexM F

Age

Height Weight Presenting problem or proposed surgery Please list the name and date of all previous surgeries Complications from above surgeries (if any) Have you ever had a Blood Transfusion Yes No If yes, when Do you smoke? Yes No If yes, how many a day? Are you currently taking any medications? Yes No If Yes, please list. Are you allergic to any medications? Yes No If Yes, please list. Type of allergic reaction Please check all conditions that apply High Blood Pressure Diabetes Anemia Heart Attack Chest Pain/Tightness Heart Murmurs Stroke Cancer Tuberculosis Abdominal Bleeding Emphysema Thyroid Problem Lung Problems/Asthma Shortness of Breath Family History of Cancer Hepatitis Family history of DVT/PE Oral Contraceptive/Hormone Replacement Therapy Malignancy Other Illnesses not listed

FEMALES ONLY:

Are you currently pregnant? Yes No How many pregnancies have you had? How many live births? Did you breast feed? Yes No
Family history of Breast Cancer? Yes No
Date of Last Mammogram

I confirm that this information is valid and current.

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Elizabeth Kinsley MD • 1441 Ochsner Blvd • Covington, LA 70433 • (985) 893-3737 • Dr. Kinsley on Google Earth

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Patient History

FEMALES ONLY:

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Call Today: 866.625.6837