Karen E. Schneider, M.D
130 EAST 77TH STREET
NEW YORK, NY 10075
FORM C
PATIENT QUESTIONNAIRE
Patient Name:DOB: / Surgeon (If applicable) :
Complaint & Brief Description of Injury or Problem: Right or Left
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Please list ALL PAST SURGERIES: (Indicate right or left side)
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ANESTHESIA problems: □ Yes □ No
If Yes, please list:
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Please list ALL MEDICATIONS, including DOSAGE:
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List any ALLERGIES (medications/food/inhalant):
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Do you smoke? □ Yes □ No
Did you previously smoke? □ Yes □No
Packs per day:______for______years Quit ______
Do You drink alcohol? □ Yes □ No
Number of drinks per week______
Do you use recreational drugs? □ Yes □ No
Please List______How often______
Please list any non-prescription medication:
(e.g. cold tablets, vitamins)
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Please list any HERBAL:
(e.g. Cava-Cava, Ginkgo, Ginseng, St. John’s Wort, Echinacea)
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______/ Please check any symptoms you have recently experienced:
□ Fever/chills □ Weight loss
□ Weakness □ Fatigue
□ Pain (identify location): ______
□ Other: ______
Please list ALL YOUR medical conditions:
□ Anxiety □ Kidney Disease
□ Arthritis □ Liver disease
□ Asthma □ Pacemaker
□ Bleeding problems □ Palpitations/irregular heart
□ Bronchitis □ Atrial Fibrillation
□ Chest pain □ Reflux
□ COPD □ Seizure
□ Pneumonia □ Shortness of breath
□ Diabetes □ Sickle cell
□ Depression □ Anemia
□ Excessive bruising □ Sleep apnea
□ Glaucoma □ Stroke
□ Heart Attack □ TB
□ Heat/Cold problems □ Thyroid disease
□ Hiatal hernia □ Ulcer
□ High blood pressure □ Urinary problems
□ Lyme Disease: ______
□ Cancer: ______
□ Other Heart Related Issues: ______
□ Rheumatologic Issues: ______
□ Other:______
Family History of Medical Conditions:
□ Asthma □ Heart
□ Cancer □ High blood pressure
□ Diabetes □ Stroke
□ Emphysema
□ Genetic Conditions:______
□ Other:______
List your primary care physician:
Name:______
Address:______
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Telephone:______
Date: ______Patient Signature: ______