Description:

Form from HIS OpenVistA

  1. 2/18/12 2/18/12 -
  2. 8/7/14 8/7/14 - Martin Dugas
  3. 8/9/14 8/9/14 - Martin Dugas
  4. 6/26/15 6/26/15 - Martin Dugas
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June 26, 2015

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Creative Commons BY-NC 3.0 Legacy
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HEALTH HISTORY I_ANESTHESIA MULTIDISCIPLINARY

  1. StudyEvent: HIS
    1. HIS
Overview
years
cm
kg
°C
beats/min
mmHg
Anesthesia Specific
Are you allergic to adhesive tape?
Are you allergic to rubber products?
General anaesthesia (GA)
Spinal Anaesthesia
epidural anesthesia
Regional Anesthesia Procedure
Local anaesthesia (LA)
anesthetic: Moderate sedation
anesthetic: Axillary block
Health History - Endocrine
Diabetes mellitus
Hyperthyroidism
Hypothyroidism
Health History - Neurologic
Health History - Cardiovascular
Health History - Respiratory
Health History - Genitourinary
Haemodialysis
Peritoneal Dialysis (PD)
Health History - Gastrointestinal
Health History - Other
DO YOU HAVE DENTURES
DO YOU HAVE BRIDGEWORK
DO YOU HAVE CAPPED TEETH
DO YOU HAVE LOOSE TEETH
Health History - Women's health
pregnant
Health History - Substance abuse and Smoking
Do you currently smoke/use tobacco products?
Have you ever smoked /used tobacco products?
Pediatric Smoking: Does anyone in your household currently use tobacco products?
Has anyone in the house hold quit using tobacco products in the last 12 months?
Tobacco/Smoking Cessation information/advice given to Patient
Tobacco/Smoking Cessation information/advice given to Other
Immunizations
SPECIALTY CLINIC specific
Nutrition
kg
Have you experienced any unexplained weight loss or gain in the past 6 months?
Assistance / Mobility
Do you live alone?
Needs assistance at home

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