Shouldice Hospital

MEDICAL INFORMATION QUESTIONNAIRE

For patients living at a distance, this Medical Questionnaire can help us to arrange your examination, admission and operation all in one visit. However, it is only after the personal examination that a final diagnosis and treatment plan can be made.

The completion and return of this questionnaire will not put you under any obligation whatsoever.

Please be sure to answer ALL questions and all sections.

If you wish, please use our fax number listed below to transmit your completed questionnaire.

All information will be treated as confidential.

Section A

Family Name (Last Name): _____________________________________________________

First Name/Initial: __________________________________________________________

Address: _____________________________________________________________________

City: ________________________________________________________________________

State/Prov: ________________________________ Zip/Postal Code: ________________

Home Phone No.(     )______________________ Birth date(mm/day/yr): ___________
 
Gender:    M    F   Marital Status:   Married    Single    Divorced    Widowed

Religion: __________________________________ Language: _______________________

Next of Kin: _______________________________ Telephone: ______________________

Are you a former patient of Shouldice Hospital?   Yes   No   What year? 19____

Occupation/Retired: ________________________________ Self Employed:  Yes    No

Name of Company: ______________________ Business Phone No.(     )_____________

Height (feet/inches): _________________ Weight - nude (lbs): _________________

Recent weight gain? (lbs): ____________ Recent Weight Loss? (lbs): ___________

Waist - relaxed (ins.): _______________ Chest - not expanded (ins.): _________

What is your preferred admission date?
(Please give as much advance notice as possible): ____________________________

How did you hear about Shouldice Hospital?
     Friend     Article     Medical Doctor     Other _________________________

<NO ADMISSIONS ON FRIDAY, SATURDAY OR SUNDAY

THIS IS TO BE COMPLETED BY ONTARIO PATIENTS ONLY

Health Card #:    

Is this a Worker's Compensation case? 
If 'Yes' accident date?  
Claim #: 
Social Insurance #: 



Section B
MARK WITH AN "X" THE POSITION OF EACH HERNIA YOU WANT TO BE REPAIRED



Section C

DESCRIBE ONLY HERNIAS THAT YOU WANT REPAIRED
	
INGUINAL and FEMORAL HERNIAS
RIGHT GROIN
Is this your first RIGHT groin hernia?____Yes   ____No
If not, how many previous RIGHT repairs have there been?____ Date of last repair: ________
Size of this hernia: ____ Walnut(or less)   ____ Hen's egg   ____ Grapefruit(or more)


LEFT GROIN
Is this your first LEFT groin hernia?____Yes   ____No
If not, how many previous LEFT repairs have there been?_____ Date of last repair: ________
Size of this hernia: ____ Walnut(or less)   ____ Hen's egg   ____ Grapefruit(or more)


UMBILICAL, EPIGASTRIC HERNIAS
Is this your first UMBILICAL, EPIGASTRIC/OTHER hernia?____Yes  ____No
If not, how many previous repairs have been attempted on this hernia?______
Date of last repair: ______ Was there a wound infection after last repair?____Yes  ____No
Size of this hernia: ____ Walnut(or less)   ____ Hen's egg   ____ Grapefruit(or more)
 

INCISIONAL HERNIAS
Was the original operation for:
___Appendix  ___Gallbladder  ___Stomach  ___Caesarian  ___Hysterectomy  ___Colon  ___Other
How many repairs have been attempted on this hernia?_______ Date of last repair:_________ 
Was there ever a wound infection?___ Yes   ___ No
Size of this hernia: ____ Walnut(or less)   ____ Hen's egg   ____ Grapefruit(or more)



Section D
List ALL medicines, pills and drugs that you have been taking during the past six months
(including nerve and sleeping pills, anything with aspirin and other non-prescription
medicines.

______________________________________________________________________________

______________________________________________________________________________

Section E
HAVE YOU EVER HAD, PAST OR PRESENT...

1.  an abnormal reaction to a local or general anaesthetic?	Y	N	DK
    has anyone in your family had an abnormal reaction?		Y	N	DK
2.  a heart attack, angina pain, irregularity or other illness
    or trouble with your heart?					Y	N	DK
3.  abnormal blood pressure, high or low?			Y	N	DK
4.  to take medicine or pills for your heart or high blood 
    pressure?							Y	N	DK
    If YES, please list in 'Section G'
5.  difficulty with breathing, unusual tiredness or weakness	Y	N	DK
    If YES, please list in 'Section G'
6.  asthma, emphysema, chronic bronchitis, tuberculosis or 
    other lung illnesses?					Y	N	DK
7.  to take pills or medicines for asthma?			Y	N	DK
    If YES, please list in 'Section G'
8.  an allergic reaction to anything?				Y	N	DK
    If YES, please list in 'Section G'
9.  to take prednisone, cortisone, ACTH, or related medicines?	Y	N	DK
    If YES, please list in 'Section G'
10. kidney illness or problems with urination?			Y	N	DK
11. diabetes or abnormal blood sugar?				Y	N	DK
12. problems with digestion, bowel function, unusual bleeding
    or vomiting?						Y	N	DK
13. jaundice or hepatitis? When?________________		Y	N	DK
14. sexually transmitted disease (V.D.)				Y	N	DK
15. tested HIV positive						Y	N	DK
16. a stroke, unusual dizziness or blackouts?			Y	N	DK
17. severe or unusual bleeding following dental extractions or
    trauma?							Y	N	DK
18. Do you have any loose, capped or false teeth?		Y	N	 
    If YES, please list in 'Section G'
19. Do you wear contact lenses?					Y	N
20. Do you smoke? How many per day? ____________			Y	N	DK
21. How much alcohol do you drink a week? ____________________
22. List all types of surgery you have had in your life, with approximate dates
23  List all other significant illnesses you have had in your life, with approximate dates
    If YES, please list in 'Section G'
24. What other illnesses or health problems do you have NOW?
    If YES, please list in 'Section G'

General Health
25. Is your health NOW? ____Good    ____Fair   ____Poor - if poor please list in 'Section G'


Section F
Name, address and phone number of physician to contact should additional medical information
be required.

_________________________________________________________________________________

_________________________________________________________________________________

Section G
Detailed Answers (use a separate sheet if necessary)

Question #    Detailed Answer
________     _____________________________________________________________________

________     _____________________________________________________________________

________     _____________________________________________________________________

________     _____________________________________________________________________

________     _____________________________________________________________________




	

		

		

			

				

				

					
FOR OFFICE USE ONLY


				
				

					
Date Received  _____________________
					
Special Instructions:
				
				

					
Booking:     Mail      Office
					
___________________________________
				
				

					
Type of Hernia  _____________________
					
___________________________________
				
				

					
Weight Loss (lbs)
					
___________________________________
				
				

					
Approved by:  ______________________
					
___________________________________
				
				

					
 Medical Consultant
					
___________________________________
				
				
			
		
	
		
	
	


_____________________________             ______________________
Patient Signature                         Date