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Surgical History
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Provider Name
Patient Information
*
Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.
Birth Month
January
February
March
April
May
June
July
August
September
October
November
December
Birth Day
1
2
3
4
5
6
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11
12
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31
Birth Year
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
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1996
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1993
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1991
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1989
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
Surgical History
* Required Information
Please mark all surgeries you have had.
I have had no Surgeries
Anal fissure repair
Hemorrhoidectomy
Neck Disc Surgery
Tonsillectomy
Appendectomy
Low Back Disc Surgery
Sinus Surgery
Ulcer Surgery
Deviated Nose Septum
Vasectomy
Tubal Ligation
Prostate Surgery
TURP
Removal
Gallbladder Surgery
Open
Laparoscopic
Colon Polyp Removal
Open
Colonoscopy
Colon Removal
Partial
Complete
Hysterectomy (due to cancer)
Partial
Complete
Hysterectomy (not due to cancer)
Partial
Complete
Dilation and Curettage (D&C)
Single
Multiple
Spinal Fusion
Neck
Lower Back
Spinal Decompression
Neck
Lower Back
Lung Surgery
Left
Right
Both
Kidney Removal
Left
Right
Both
Cataract Surgery
Left
Right
Both
Breast Cancer Lump Removal
Left
Right
Both
Mastectomy
Left
Right
Both
Breast Reconstruction
Left
Right
Both
Breast Reduction
Left
Right
Both
Ovary Removal
Left
Right
Both
Carpal Tunnel Surgery
Left
Right
Both
Rotator Cuff Repair
Left
Right
Both
Arthroscopic Shoulder Surgery
Left
Right
Both
Hip Fracture & Surgery
Left
Right
Both
Total Hip Replacement
Left
Right
Both
Total Knee Replacement
Left
Right
Both
Arthroscopic Knee Surgery
Left
Right
Both
Foot Surgery
Left
Right
Both
Varicose Vein Procedure
Left
Right
Both
Mastoidectomy
Left
Right
Both
Thyroid Removal
Left
Right
Total
Partial
Breast Biopsy
Left
Right
Both
Multiple times
Carotid Artery Surgery
Left
Right
Both
Multiple times
Open Inguinal Hernia Surgery
Left
Right
Both
Multiple times
Laparoscopic Inguinal Hernia Surgery
Left
Right
Both
Multiple times
Caesarean Section
1
2
3 or more
Heart Valve Replacement
Mitral
Aortic
Tricuspid
Unknown Valve
Heart Bypass Surgery
1 vessel
2 vessels
3 vessels
4 or more vessels
Unknown number of vessels
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