Health History Questionaire
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- Marjory Burke
- 5 years ago
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1 Patient DOB: Patient Name: Date: Health History Questionaire Who referred your consultation? If no one referred you, how did you hear about us? Who is your primary care physician? Have you ever seen a gastroenterologist? Please list their name(s). Yes, I am under the care of a gastroenterologist. Yes, I have seen one in the past, but not currently. No, I have never seen a gastroenterologist. Please list your preferred pharmacy What is your primary concern for today's visit? Have you recently experienced any of the following? (Please check all that apply) Trouble Swallowing Weight Loss Abdominal Bloating Food Gets Stuck Weight gain Abdominal pain Choking Change in appetite Recent change in bowel habits Heartburn Feeling full early Diarrhea Nausea Sore Throat Constipation Vomiting Voice Hoarseness Black Tar-like stools Regurgitation Congestion Bleeding from rectum Belching Throat Clearing Vomiting Blood Fevers or chills Shortness of breath Heat or cold intolerance Fatigue Difficulty breathing Trouble with urination Headaches Cough Frequency of urination Dizziness Chest Pain Joint pain or swelling Blurry Vision Palpitations Recent mood changes Double vision Yellowing of eyes or skin Memory changes Hearing changes Skin rashes or lumps Frequently anxious
2 Have you ever been treated for or had issues with any of the following? (Please check all that apply) Cancer : Ulcers Back/Spinal problems Hay fever Chronic Diarrhea Kidney Stones Food allergies Colon Polyps Other Kidney Problems Heart Attack Diverticulosis/Diverticulitis Goiter or thyoird trouble Irregular Heartbeat Irritable or spastic colon Diabetes Valvular heart disease Colitis Anemia (low blood count) Congestive Heart Failure Gallstones Blood clot in lungs or legs High blood pressure Pancreatitis Other blood disorders High cholesterol Hepatitis Poor Circulation Pneumonia Other Liver Disease Arthritis Asthma Genital Disorders Stroke Empysema or Bronchitis Prostate Trouble Seizures Other lung disease Endometriosis Depression or Anxiety Have you every had the following operations? (Please check all that apply) Fundoplication/ Anti-reflux Surge Removal of appendix Eye Surgery Myotomy for Achalasia Hemorrhoid Surgery Tonsillectomy Removal of partial/all of stomach Removal of Spleen Prostate surgery Gastric bypass Removal of part/all of colon Hysterectomy Gastric sleeve Heart Bypass Ovearies Removed Lap Band placement Angioplasty Tubes tied Hiatal hernia repair Replacement of Heart Valve Removal of Kidney Any other surgery on the Artificial blood vessel graft Placement of artificial joint esophagus or stomach? Inguinal hernia repair Removal of gallbladder Removal of gallbladder Have you every had the following procedures (Please check all that apply) Upper endoscopy ( a lighted camera that goes into your mouth usually while you are sedated) Barium Swallow or Esophagram (You drink barium and are placed in different positions for X ray pictures) Esophageal motility study (a catheter that goes through your nose and you drink atleast 10 sips of salty water) Esophageal ph catheter based monitoring (a catheter that goes in your nose and monitors acid for 24 hours) Esophageal ph wireless monitoring (a caspsule attached to your esophageal lining to monitor acid) Colonoscopy Please list any other medical conditions or operations:
3 Patient Name: Patient DOB: Please list any food or drug allergies and the reaction: Please list all medications you currently take or provide your current medication list on another sheet: Name, Dose, and Frequency of Medication: Please circle yes or no for each of the following questions. Are you on medications for diabetes? Yes No Are you on steroids? Yes No Are you on any blood thinners? Yes No Are you currently taking an acid suppression tablet regularly? Yes No Have you ever been told you have a difficult airway or intubation? Yes No Have you ever had a problem with anesthesia. Please explain. Yes No Do you have sleep apnea or do you currently use a CPAP machine? Yes No Family History Please list any significant medical condition Father: Alive Deceased Medical Problems/Cause of Death: Mother: Alive Deceased Medical Problems/Cause of Death: Number of Siblings: Sisters Brothers Number of Children: Sons Daughters Is there any family history of the following? Please list the family member. Esophageal Cancer Heart Disease Stomach Cancer Colon Cancer Diabetes Eosinophillic Esophagitis Celiac Disease Breast Ovary Endometrial or Uterine Cancer Liver Disease Pancreatic Disease Other cancers Ulcerative Colitis Crohn's Disease
4 Social History Please list your current marital status: Who lives at home with you? What is the highest level of education you have achieved? Some School Some College Masters or Doctorate Degree Highschool College Degree In regards to school or work, check all that apply: Working full time Stay at home parent / caregiver In School Working part time Retired What is your occupation / trade? Tobacco Have you used tobacco products? Types of Tobacco used (check all that apply): Never smoked Cigarette Chewing products Current user Cigars Vapor Former user If you are a current tobacco user, how often do you use tobacco? If you are a current tobacco user, how often do you use tobacco in a day? If you are a former tobacco user, how long has it been since your last use? How many years have you used tobacco? Alcohol Have you had a drink with alcohol in the past year? No Yes If yes, How often have you had a drink containing alcohol in the past year? Never Monthly or Less 2-4 Times a month 2-3 Times a week 4 or More Times a Week If yes, how many drinks did you have on a typical day when you were drinking? If yes, please check all types of alcohol that was consumed: Beer Wine Hard Liquor Drugs Do you smoke Marijuana? No Yes If so, how frequently? Do you use any other illicit drugs? Please list: Have you used any IV drugs (requring a needle)? Please list: Do you have any tattoos? No Yes Do you have any piercings? No Yes Where? Signature: Date:
5
PATIENT HISTORY FORM
PATIENT HISTORY FORM Date: Page 1 of 5 Last Name: First Name: Middle Initial: Referred By: Age: Primary Care Doctor: Please provide name(s) of other physician(s) that you have visited within the last year:
Patient History Form
Acct #: Patient History Form Please answer ALL questions by filling out the appropriate box(es). Name: Gender: M F Primary Care Provider: DOB: Today s Date: Referring Provider (if different from PCP):
Patient Interview Form
Patient Interview Form Patient Information First Name: Last Name: Date of Birth: Age: Email Personal: Race Select one or more Referring Physician White Black or African Asian American Indian Native Hawaiian
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Date: Telephone Number: Age: Address: Email address: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3)
Patient Interview Form
Page 1 of 5 Orange Coast Memorial Office: 18111 Brookhurst Ave. Suite 5200, Fountain Valley, CA 92708 * Tel: (714) 962-7705 * Fax: (714) 861-4552 www.unitedgi.com Patient Interview Form Patient Information
Johns Hopkins Hospital Division of Gastroenterology Patient Questionnaire
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New Patient Medical History Form Date: Name: Date of Birth: Address: City: ZIP: Home Phone #: Cell Phone #: Emergency Contact: Relationship: Emergency Contact Phone #: Primary Care Physician: Referring
JOHN MICHAEL ROACH, MD
GASTROENTEROLOGY JOHN MICHAEL ROACH, MD 520 N. 4 TH AVE. PASCO, WA 99301 Phone: (509) 546-8383 Name: Date of Birth: First Middle (full) Last m/d/yr Primary care provider: Referring physician: Local Pharmacy:
New Patient Questionnaire. Name DOB Date
Medical History (This refers to medical problems that have already been diagnosed or treated. Please explain how this is treated, such as diet, medication, surgery, etc.) Condition Abnormal Pap smear Alcohol
Patient History Form
Patient Personal Information Name: Date: Age: Occupation: Employer's name: Briefly describe your daily activities at work: Sex: male female Marital Status: single married divorced widowed Spouse's name:
PATIENT INFORMATION. Are we currently seeing one of your family members at our practice, or have we previously? YES patient s name:
PATIENT INFORMATION Date Name Address First Middle Last City State Zip Home # Cell # Check this box to authorize text messaging for confirming and reminders Email Check this box to authorize our office
Bend Surgical Associates. Michael J. Mastrangelo, MD, FACS. Medication Name Dosage Frequency Medication Name Dosage Frequency
Bend Surgical Associates Michael J. Mastrangelo, MD, FACS PATIENT NAME: DATE F BIRTH: MEDICATINS Please list all of your current prescription, non-prescription medications, vitamins, minerals, and supplements.
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
Patient Interview Form
Page 1 of 6 Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: Notes: Email Please check one as your preferred email for communications Personal: Work: Race Select
Please list any medications you currently taking along with dosage and directions (including birth control, vitamins and OTC medications):
Name: DOB: Date of Appointment: Please list all doctors you currently see (Primary Care Physician and Specialists i.e. Cardiologist): Please list any medications you currently taking along with dosage
PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: EMERGENCY CONTACT INFORMATION PRIMARY INSURANCE INFORMATION
PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: Gender: SSN: Race: Marital Status: Address Line: City: State: Zip Code: Home Phone: Work Phone: Email Address: Cell Phone: Primary Care
Patient Interview Form
Page 1 of 5 Physicians: D.F. Jackson, III, MD William D. McLaughlin, MD Robert P. Albares, MD Jeffrey J. Crittenden, MD Physicians: Samuel J. Tarwater, MD Travis J. Rutland, MD Ashwani Kapoor, MD Pathologist:
PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS:
1 NAME: DATE OF BIRTH PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS: PAST MEDICAL HISTORY (YOUR MEDICAL HISTORY) :
Modesto Gastroenterology Medical Corporation
Page 1 of 5 Modesto Gastroenterology Medical Corporation Magdy S. Elsakr, M.D. Board Certified Gastroenterologist 2336 Sylvan Avenue, Suite A, Modesto, CA 95355, Phone: 209-338-0292, Fax: 209-338-0298
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Patient Interview Form
Page 1 of 5 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Age: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more
Patient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
Patient Interview Form
Page 1 of 5 Gastroenterologists: D.F. Jackson, III, MD William D. McLaughlin, MD Robert P. Albares, MD Jeffrey J. Crittenden, MD Samuel J. Tarwater, MD Travis J. Rutland, MD Gastroenterologists: Marc L.
ADVANCED GASTROENTEROLOGY & ENDOSCOPY, P.C. ALI S. KARAKURUM, MD, FACP, FACG
ADVANCED GASTROENTEROLOGY & ENDOSCOPY, P.C. ALI S. KARAKURUM, MD, FACP, FACG DATE SOC. SEC. NUMBER FULL NAME DATE OF BIRTH ADDRESS: STREET TOWN STATE ZIP PHONE: HOME WORK CELL EMPLOYER OCCUPATION ADDRESS
PATIENT INFORMATION Please print clearly and complete all blanks
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GASTROINTESTINAL & MINIMALLY INVASIVE SURGERY HEALTH HISTORY QUESTIONNAIRE Date Patient Name _ Date of Birth Age Daytime phone ( ) Other phone ( ) Email How did you hear about us? My doctor Yellow pages
Name: Today s Date: Address: State, Zip Code
New Patient Health History Questionnaire Name: Today s Date: Address: City State, Zip Code Email Address: Date of Birth: Home Telephone #: Cell Number: Work Number: Emergency Contact name & number: Referred