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Dr. McGarry new patient form

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Dr. McGarry new patient form
Sean McGarry, M.D.
Orthopaedic Oncology
ORTHOPAEDICS
Name: _____________________________
Primary Doctor
Address_____________________________
City______________ State____ Zip______
Phone_____________Fax_______________
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DOB: __________ Age: ____ Sex: M
F
Referring Doctor (if different)
Address_____________________________
City______________ State____ Zip______
Phone_____________Fax_______________
Review of Systems: Are you currently having or have you recently had any problems with
the following?
Yes
No
Describe all yes answers
Eyes, Vision
Ears, Nose, Throat
Lungs, Breathing
Digestion, GI Problems
Bowel, Bladder Problems
High Blood Pressure
Heart Ailments
Bleeding Problems
Blood Clots
Blood Transfusions
Balance Problems
Numbness, Tingling
Blackouts, Fainting
Epilepsy, Seizures
Muscle Weakness
Muscle Spasms, Spasticity
Psychological Problems
Cancer
Arthritis
Diabetes, Blood Sugar
Weight Loss or Gain
Infections
Fevers, Chills
Night Sweats
Other
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Allergies: List all medications and substances to which you are allergic:
√
What reaction did you have?
None
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Penicillin
Sulfa
Iodine
Latex
Other
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Page 1 of 2
Orthopaedic Clinic | 989265 Nebraska Medical Center | Omaha, NE 68198-9265
PH: 402-559-8000 | FX: 402-559-8746 | www.unmc.edu/orthosurgery
Kerby Selmer, RN
402-559-5611
Sean McGarry, M.D.
Orthopaedic Oncology
ORTHOPAEDICS
Medical Problems: Check all of the medical problems you have had in your lifetime:
 High Blood Pressure
 Irregular Heart Rhythm
 Coronary Heart Disease
 Heart Attack
 Heart Valve Disease
 Peripheral Vascular
Disease
 Blood Clots
 Asthma
 Lung Disease
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Tuberculosis (TB)
Kidney Disease
Stomach Ulcer
Arthritis
Brain Injury
Cerebral Palsy
Nerve Injury
Diabetes
Cancer
Diverticulitis
Seizures
Polio
Multiple Sclerosis
Injury
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Kerby Selmer, RN
402-559-5611
Thyroid Disease
Hepatitis A B C
Osteoporosis
Stroke
Spinal Cord Injury
Parkinson’s Disease
Other (list)
Current Medications: List all current prescription and herbal medications you are taking:
Medication
Dose
Frequency
Medication
Dose
Frequency
Surgical History: List all the operations you have had in your life:
Year
Type of Operation
Year
Type of Operation
Social History:
Occupation____________________________________ Full-time
Part-time
Retired
Do you currently use tobacco? Yes No Did you previously use tobacco? Yes No 
Pipe CigarChewing tobacco For how long?_____yrs
Cigarettes____packs/day
Do you drink alcohol?
History of substance abuse?
Yes No
Yes No
How Often? Daily 1-2x/wk 1-2x/mo1-2x/yr
What substance?_________________________
Family History: Do you have any blood relatives with any of the following conditions?
 High Blood Pressure
 Irregular Heart Rhythm
 Coronary Artery Disease
 Heart Attack
 Heart Valve Disease
 Peripheral Vascular
Disease
 Blood Clots
 Stroke
 Diabetes
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Asthma
Thyroid Disease
Hepatitis A
Seizures
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 BC
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Lung Disease
Kidney Disease
Osteoporosis
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Tuberculosis (TB)
Cancer
Arthritis
Other (list)
Signature__________________________________ Date_______________
Reviewed by:
Date Reviewed by:
Date Reviewed by:
Date Reviewed by:
Page 2 of 2
Date
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