hernias
 

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Fax: 216.591.1424

Name:

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Telephone Numbers

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Doctor

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:

Current Medication You are Taking:
Name
Dose

List previous MAJOR Surgery:

HERNIA INFORMATION

Location
 Groin Right
 Groin Left
 Abdominal Wall - Upper
 Abdominal Wall - Lower
 Bellybutton
 Other (femoral/ lumber/ flank/ etc.)|

How long have you had a hernia:
weeks months years

PREVIOUS HERNIA SURGERY:
 No
Yes

If Yes,

Year Location (what part of body)
yyyy

Immediate family members with GROIN hernia:
 Mother Brother Sister Child





Commerce Professional Center • 24025 Commerce Park Road • Beachwood, Ohio 44122
VOICE: 216.591.1422 • FAX: 216.591.1424