Hernias - Medical Form

Name:

Age: Date of Birth:
Address:
Apt#:
City:
State: Zip:

Telephone Numbers

Home:
Cell:
Office:

Height: Weight: lbs.

MEDICAL HISTORY

Glaucoma Cataracts Stroke Seizures
Mental Illness

High Blood Pressure Heart Attack Chest Pain
Arrhythmia (abnormal heart rhythm) Mitral Valve Prolapse
Pacemaker Easy Bleeding

Shortness of Breath Emphysema Pulmonary Embolus Asthma

Hiatal Hernia Acid Reflux Rectal Bleeding
Ulcers  Hepatitis Intestinal Cancer

Kidney Stones Difficulty Urinating
Frequent Nighttime Urinating

Diabetes Thyroid Disorder

Arthritis Orthopedic Mental Implants Phiebitis

Cigarette Smoker Alcohol in Excess

Other Major Disorders

Allergies to medication:
Penicillin Sulfa Codeine
Other:

List previous MAJOR Surgery:

HERNIA INFORMATION

How long have you had a hernia:

PREVIOUS HERNIA SURGERY:
No
Yes

If Yes,

Immediate family members with GROIN hernia:
Father Mother Brother Sister Child

Hernias:
Looking for hernia surgeons, hernia doctors or information about hernias? The Hernia Center of Ohio, located in suburban Cleveland, Ohio, specializes in the repair of all types of hernias, including incisional hernias, hiatal hernia treatments and inguinal hernia repairs.

Patients travel from around the world. In Northeast Ohio, we can serve patients from such communities as Beachwood, Lakewood, Mentor, Pepper Pike, Parma, Chagrin Falls, Mayfield Heights, Brecksville, Cleveland, Akron, Canton and more.