7750 Bayview Avenue INFORMATION Thornhill, ON L3T 4A3

Shouldice HospitalMEDICALINFORMATIONQUESTIONNAIRE7750 Bayview AvenueThornhill, ON L3T 4A3Tel: 905‐889‐1125Fax: 905‐889‐4216Toll Free: 1‐800‐291‐7750For patients living at a distance, this Medical Questionnaire can help you arrange your examination,admission and surgery all in one visit. However, it is only after the personal examination at our Clinic thata final diagnosis and treatment plan can be made.The completion and return of this Questionnaire will not put you under any obligation whatsoever.Please be sure to answer ALL questions and all sections.THIS FORM CAN BE COMPLETED ON YOUR COMPUTER AND SAVED, THEN EMAILED BACK TOOUR OFFICE. THE EMAIL ADDRESS IS medicalquestionnaire@shouldice.comIf you do not wish to email this form for reasons of internet confidentiality, please fax or mail the printedForm to the Hospital.On receipt by Shouldice Hospital, all information will be treated as confidential. Please allow 2-3 businessdays for a Shouldice Surgeon to review and respond to your Questionnaire.ALL QUESTIONS MUST BE ANSWERED ACCURATELY – please print clearly.Incomplete or inaccurate answers may necessitate delay or cancellation of surgery. If in doubt, pleaseconsult your family physician.Section AFamily Name(Last Name):First Name/Initial:Address:City:Province/State:Postal Code/Zip:Home Phone(999‐999‐9999):Birth Date(dd/mm/yyyy):GenderMarital owedEmail Address:Emergency Contact:Shoul dice Medical Informa tion Ques tionnai reTelephone(999‐999‐9999):version20131113Pa ge 1 of 7

Have you had surgery atYesNoIf yes, what year?Shouldice Hospital before?Have you previously been examined at Shouldice Hospital or submitted amedical questionnaire?Cell Phone No.Occupation/Retired:(999-999-9999)Business Phone No.Name of eet/inches)Current weight – nude(pounds)Recent weight gain (pounds)Recent weight loss (pounds)Waist at the navel,relaxed (inches)Chest-not expanded (inches)What is your preferredadmission date?Preferred method ofcommunication:MailEmail(Please give as much advance notice as possible. There are no admissions on Friday or Saturday. Sundayadmissions are reserved for those patients who have previously been examined at Shouldice Hospital. Alladmissions are one day prior to surgery.)How did you hear aboutShouldice Hospital?FriendArticleMedical DoctorInternetOtherName, address and phone number of family physician to contact should additional medical information /Zip:Telephone:Fax:TO BE COMPLETED BY ONTARIO PATIENTS ONLYHealth Card Number:Is this a Workers’ Compensation Case?Shoul dice Medical Informa tion Ques tionnai reYesversion20131113NoPa ge 2 of 7

Section BPlace a checkmark on the position of eachhernia you want repaired:(Hiatus, Flank and Parastomal Hernias are not repairedat Shouldice Hospital)EPIGASTRIC Hernias are above the navel (“belly button”)UMBILICAL Hernias are at the navel.INGUINAL AND FEMORAL HERNIAS are in thegroin area on either side.INCISIONAL Hernias bulge through the scar of anyother type of surgical operation that has failed tohold.OTHER Hernias are through any othermuscular weakness.Section CDESCRIBE ONLY THE HERNIAS THAT YOU WANT REPAIREDINGUINAL and FEMORAL HERNIASRight GroinIs this your first RIGHT groin hernia?Date of lastrepair (m /y ):YesNoIf no, number of previous RIGHT repairs?Can you reduce (push back in) your hernia?Size of hernia:No noticeable bulgeHen’s eggYesNoWalnut (or less)Grapefruit (or more)Left GroinIs this your first LEFT groin hernia?Date of lastrepair (m /y ):YesNoIf no, number of previous LEFT repairs?Can you reduce (push back in) your hernia?Size of hernia:No noticeable bulgeHen’s eggYesNoWalnut (or less)Grapefruit (or more)UMBIL ICAL, EPIGASTRIC and OTHER HERN IASIs this your first UMBILICAL,YesNoIf no, number of previous repairs?EPIGASTRIC/OTHER hernia?Date of lastCan you reduce (push back in) your hernia?YesNorepair (m /y ):No noticeable bulgeWalnut (or less)Size of hernia:Hen’s eggGrapefruit (or more)INCISIONAL HERNIASAppendixGall BladderStomachWhat was the original operation for:How many previous repairshave been attempted on this hernia?Size of hernia:Shoul dice Medical Informa tion Ques tionnai reCaesarianHysterectomyOtherColonDate of last repair(dd/mm/yyyy):No noticeable bulgeWalnut (or less)Hen’s eggGrapefruit (or more)version20131113Pa ge 3 of 7

ADDITIONAL INFORMATION ABOUT YOUR HERN IAHas the hernia(s) identified above beendiagnosed by a medical doctor?:If yes how?No (Self Diagnosed)YesPhysical ExamUltrasoundOtherAre you experiencing chronic pain fromthe hernia(s) identified above?YesNoAre you experiencing any chronic painfrom a previous hernia repair?YesNoHave you experienced a wound infectionin any previous surgery?YesNoWas mesh used in your other priorhernia surgery?YesNoSection DHAVE YOU EVER HAD, PAST OR PRESENT 1.2.an abnormal reaction to a local or generalanesthetic or history of malignant hyperthermia?a family member that has had an abnormal reaction toanesthetic?YESNO?YN?YN?3.heart trouble, heart attack, angina, mechanical valvesor irregular heart beat?YN?4.abnormal blood pressure, high or low?YN?5.medicine for your heart or high blood pressure?YN?6. difficulty with breathing or had unusual tiredness orweakness?YN?7. lung illness, asthma, emphysema, chronic bronchitis, ortuberculosis?YN?8.medicine for asthma or other lung illness?YN?9.kidney illness or problems with urination?YN?YN?YN?YN?YN?YN?YN?YN?YN?10. severe or unusual bleeding following any trauma, cut ordental extraction?11. a blood disorder (high or low platelets, h emoglobin orwhite cells)?12. blood clots in the legs (DVT) or in the lungs (pulmonaryembolism)?13. diabetes or abnormal blood sugar ?14. problems with digestion, bowel function, bleeding orvomiting?15. jaundice, hepatitis, cirrhosis, or ascites (fluid in theabdomen)? When? Type?16. a sexually transmitted disease or been exposedto/tested positive for HIV?17. steroids, prednisone, cortisone, ACTH, or relatedmedicines?Shoul dice Medical Informa tion Ques tionnai reDETAILS to all Questions answered yesversion20131113Pa ge 4 of 7

YESNO?YN?YN?YN?YN?YN?23. Do you smoke? How much per day?YN?24. Do you cough or have sputum from smoking?YN?25. Do you use street or recreational drugs or are you on adrug maintenance program?YN?26. Do you drink alcohol? How much per week?YN?YN?YN?YN?YN?YN?YN?YN?YN?18. a stroke, unusual dizziness, blackouts, tremors ormemory loss?19. Do you have any neurological disorders(e.g. Parkin son’s, Epilepsy, Dementia)?20. Do you have any neuromuscular disorders(e.g. Myasthenia gravis, Multiple sclerosis)?21. Do you have any loose teeth? Capped teeth? Falseteeth?22. Do you have problems with eyesight or wear contactlenses?27. Do you have cultural or religious practices orrequirements that we should know of?28 Do you have any special needs or require supervision orattendant care (e.g. vision , mobility, dietary, Do wn’s o rTourette’s Syndro me)?29. Do you live alone or live in a retirement or nursinghome?30. Are you allergic to anything (e.g. medication, food,environmen tal, latex)?31. Are you pregnant or within 12 months of an end ofpregnancy?32. Have you undergone chemotherapy in the past 12months?33. Have you undergone radiation therapy near your herniain the past 12 months?34. Can you climb two flights of stairs without shortness ofbreath?35. How do you rate your health NOW?DETAILS to all Questions answered yesGOODFAIRPOORSection EList ALL medicines taken in the past six months (including anything with aspirin and non-prescription ornaturopathic medicines).Shoul dice Medical Informa tion Ques tionnai reversion20131113Pa ge 5 of 7

Please list all prior surgeries by date (specifying those done laparoscopically) and other significant illnesses:Patient AcknowledgmentBy checking this box You acknowledge that the information given above is accurate to the best of your knowledge.Patient NameDateIn addition, please ensure the MRSA Screening Form on Page 7 is also completed.For Hospital Use OnlyDate Received:mm / dd / yyPre-Admission (completed by Shouldice Surgeon)Type of HerniaYes, withAdmit:Weight lossrequiredMedical reportsrequiredNo, unsuitableYesNoYesNopoundsIf yes, what?:Approved by:Admission Assessment by:Date:SurgeonApproved by:Shoul dice Medical Informa tion Ques tionnai rePending, withGPNurseDate:version20131113Pa ge 6 of 7

SHOULDICE HOSPITALSCREENING forAcute Respiratory Illness (ARI ) and Antibiotic-Resistant Organism (ARO) /Methicillin-Resistant Staphylococcus Aureus (MRSA)Please complete and submit this form to be considered for admission, in addition to the Medical Questionnaire.Failure to follow these procedures will result in delay or cancellation of surgery.Print Patient’s Full NamePlease answer all questions below.Any new health issues and/or operations between the time of completing this form and your date ofadmission must be reported to the Hospital at least 2 weeks before your admission to update yourinformation.A. 1. Do you have new / worse than usual cough, shortness of breath, sore throat, severe headache?Yes No2. Are you feeling feverish, or have you had fever, shakes or chills, muscle aches within the last 24 hours?Yes No* A Nurse will check your temperature on admission C3. Travel and Contact History:a) Have you traveled to places outside Canada within the last 21 days?YesCountryNob) Have you had contact with a sick person who has traveled outside Canada within the last 21 days?YesCountryNoB. 4. Have you been admitted to an acute care hospital, an intensive care unit (ICU), coronary care unit(CCU) for at least 24 hours within the past 6 months?YesNo5. Are you a resident of a Long Term Care facility? (Nursing home, group retirement home, rehab,extended care, continuing care facility, etc.)YesNo If so, have there been any recent outbreak of acute respiratory illness (ARI) orantibiotic resistant organism (ARO, MRSA) in that facility?YesNo6. Have you worked in a facility that has had an outbreak of acute respiratory illness (ARI), gastrointestinal illness or ARO/MRSA within the past 6 months?YesNo7. Have you been told that you have had any ARO such as MRSA, VRE (Vancomycin ResistantEnterococcus), or C-diff. (Clostridium difficile)?YesNoDate:By checking this box, you acknowledge that the information you have given is true.Front Office Nurse: Practice/promote Hand Hygiene at all times & Respiratory Precautions as necessary!- Review this questionnaire upon receipt and on admission with patient for any changes to health. Any “yes” answers need to bereferred to the Examining Physician for in-depth assessment and/or further orders.- Refer to guideline for management of ARI and/or ARO/MRSA screening and for detailed precautionary measures.Date of Initial Assessment:Date of Admission/Review:Nurse SignatureNurse SignaturePatient SignatureNotes:Rev. Aug. 22/12, Jan. 24/13, Oct.15/14, Sept. 17/15

Shouldice Medical Information Questionnaire version20131113 Page 1 of 7 Shouldice Hospital 7750 Bayview Avenue Thornhill, ON L3T 4A3 Tel: 905‐889‐1125 Fax: 905‐889‐4216 To