Patient Interview Form

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1 Page 1 of 7 Patient Interview Form UNIVERSITY GASTROENTEROLOGY 33 Staniford Street, Providence, RI Phone Fax Patient Information First Name: MRN: Age: Last Name: Date Of Birth: Notes: Contact Preference Mail/Letter Home Phone Work Phone Cell Phone Patient Portal Please check one as your preferred for communications Personal: Work: Race Select one or more White Unknown Black or African American Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Ethnicity Hispanic or Latino Not Hispanic or Latino Sex Male Female Other Preferred Language English French Italian Portuguese Spanish; Castilian Allergies Patient has no known allergies Patient has no known drug allergies Codeine Sulfate Erythromycin Penicillins Demerol Sulfa (Sulfonamide Antibiotics) Nsaids (Non- Steroidal Anti- Inflammatory Drug) Aspirin Like - Salicylates IV dye: Iodine- Iodine Containing Contrast Media Latex Fentanyl

2 Page 2 of 7 Morphine Immunizations Flu Vaccine PPD tetanus toxoid Pneumonia Vaccine Shingles Vaccine

3 Page 3 of 7 Current Medications Name Dose How taken? Consent to Import Medication History I consent to obtaining a history of my medications purchased at pharmacies. Yes No Pharmacy Name Address Phone Diagnostic Studies/Tests Ultrasound- Abdomen Bone density CT Abd, Pelvis, Chest Ultrasound-Liver MRI-Abdomen Lab Work CT Abdomen CT Pelvis Past or Present Medical Conditions Anemia Anxiety disorder Arthritis Asthma Barretts Esophagus Breast cancer Colon cancer Ovarian Cancer Colon polyps Depression Diabetes Diverticulitis Gallstones Gastric Ulcer GERD Mellitus Gout Hepatitis High blood IBS Migraines pressure Lyme Disease Osteoporosis Rheumatic Fever Seizures TB exposure Thyroid disorder Sleep apnea Crohn's Disease Ischemic Heart Disease Stomach cancer Blood Kidney disease Transfusion Pancreatitis Stent Placement Lactose Intolerance Bleeding Disorder Lung Disease

4 Page 4 of 7 Previous Procedures Appendectomy Cholecystectomy Colon Resection Colonoscopy EGD ERCP Hysterectomy C-Section Tubal Ligation Mastectomy Pacemaker CABG Prostatectomy Joint Surgery/Replacement Cardiac Defibrillator Social History Occupation: Number of Children: Marital Status Single Married Divorced Separated Widowed Other Alcohol Type More than 2 days/week Less than 2 days/week Quit using alcohol Number Caffeine Intake: Tobacco Smoking Status Current every day smoker Smoker, current status unknown Current some day smoker Light tobacco smoker Former smoker Heavy tobacco smoker Never smoker Unknown if ever smoked Drug Use Type Occasional Number Daily

5 Page 5 of 7 Exercise Type Quantity Number Frequency Family Medical History No knowledge of family history No family history of Colon cancer Colon Polyps Family history unknown, Adopted Health Status Healthy Deceased/At Age Diagnoses Alcoholism Cancer, Breast Cancer, Uterus Colon Polyp Colitis Crohn's Disease Diabetes Liver Disease Lung Disease Bleeding Disorder Colon Cancer Heart Disease

6 Page 6 of 7 Review Of Systems Allergic/Immunologic HIV exposure persistent infections strong allergic reactions or hives Cardiovascular chest pain shortness of breath with exercise irregular heart beat shortness of breath when lying down palpitations peripheral edema passing out Constitutional fatigue fever loss of appetite malaise sweats weight gain weight loss ENMT difficulty swallowing dizziness ear pain nasal obstruction nose bleeds sore throat Endocrine excessive thirst hair loss heat intolerance Eyes double vision loss of vision sensitivity to light blurring irritation Gastrointestinal abdominal pain abdominal swelling change in bowel habits constipation diarrhea difficulty swallowing gas heartburn yellowing of skin nausea rectal bleeding stomach cramps vomiting black stool Genitourinary dark urine decrease in urine flow painful urination frequent urinary infections frequent urination blood in urine impotence wake up to urinate urethral discharge or incontinence Hematologic/Lymphatic bleeding gums or palpable lymph nodes easy bruising prolonged bleeding Integumentary allergies dryness hives itching jaundice lesions rashes Musculoskeletal arthritis back pain gout joint deformity joint pain muscle weakness stiffness Neurological dizziness fainting frequent headaches migraine numbness or tingling seizures tremors vertigo Psychiatric anxiety depression difficulty sleeping hallucinations nervousness panic attacks paranoia Respiratory asthma cough shortness of breath excessive sputum cough up blood shortness of breath with exercise wheezing

7 Page 7 of 7 Consent to Share Data I consent to having my medical and demographic information shared with other health care entities. Yes No Reminder Preference I would like to receive preventive care and follow up care reminders. Yes No Signature Signature Date Reviewed with Patient Parent Guardian Not Present

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