Patient Health Information Follow-Up

ONLINE FOLLOW-UP FORM

If you have medical questions or would like to make an appointment, please call our office at 410.550.0409.

Patient Name*

Day Phone*

Email Address*

Current Height

Current Weight

Surgeon

CURRENT HEALTH CONDITIONS

Please note if you presently have any of the following medical conditions:

Sleep apnea treated with CPAP, BiPAP, or uvuloplasty

Acid Reflux or GERD which requires a daily PPI or H2 blocker medication

High cholesterol or triglycerides which requires medication

High blood pressure which requires medication

Please list all medications that you take for high blood pressure:

Diabetes

Is your activity limited by musculoskeletal pain?

Do you take daily medication for musculoskeletal disease?

Have you had a surgical intervention for musculoskeletal disease since your last follow-up?

READMISSIONS OR REOPERATIONS

Have you been readmitted to any hospital for any reason since your last follow-up?

Have you had any surgical operations or procedures for any reason since your last follow-up?

If you have had a readmission, reoperation, or procedure (such as an upper GI) since your last visit, please give us more information here:

NOTES

Is there anything else you would like to share with us?