New Patient Packet — Augusta Surgical Group

Social History: Occupation

Marital Status

Primary Medical Doctor

Referring Doctor

Cardiologist

Nephrologist

Dialysis Center

Days You Dialyze

Other Doctors & Their Specialties

What medical concern brings you to the office today?

If yes, to what and what is your reaction?

List medications that you are taking:

Past Surgeries

What type of Hernia Repair and/or Surgeries?

If you have/had cancer what type and/or other medical conditions

Family Medical History

List medical conditions affecting your immediate family (If there none, type: 'N/A')

Tobacco

Do you smoke?

If yes, how many packs per day & for how many years? If former, how many years?

Alcohol

Do you drink?

If yes, how many drinks per week?

Other recreational drugs:

Obstetrical/gynecologic history:

Age at first childbirth:

Age at first period:

Are you pregnant?

Number of pregnancies:

Number of deliveries:

Personal/Religious preferences that you would like us to consider or may impact your care?

Do you CURRENTLY or have you RECENTLY had any of the conditions listed below?

Check for Yes / leave blank for No