PATIENT HISTORY FORM

Transcription

1 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: Reason(s) for your visit to a Gastroenterologist (please include duration of your symptoms if applicable: Have you started any new medications (prescription, non-prescription, vitamins, and herbal supplements) within 3 months of the onset of your symptoms? YES NO If yes, please list only those medications (including antibiotics) you started within 3 months of the onset of your symptoms: For FEMALE patients, is there any correlation between your symptoms and your menstrual period (if applicable)? YES NO If yes, please briefly describe: Have you been experiencing any of the following (please place a check mark next to those that apply to you): Nausea Shortness of breath Fever and/or chills Vomiting Coughing Stool incontinence (i.e. Burning in chest Blood in urine loss of control of bowel Acid or bitter taste in the Pain when you urinate movements) back of your throat Abdominal bloating Night sweats Voice hoarseness Abdominal pain Rash in any part of your body Awakening in the middle of the night Diarrhea Headache with coughing or shortness of breath Constipation Sudden change in vision Sensation of food being stuck in your Thinning of the stool Eye pain throat or chest after swallowing on a consistent basis Other: Pain when you swallow Rectal bleeding Loss of appetite Pain in rectal area Feeling full shortly after starting a meal Black stool Chest Pain Unintentional weight loss Please describe any other symptoms you have been experiencing that are not listed above:

2 For FEMALE Patients only: Page 2 of 5 Date of last menstrual period: Are you or could you be pregnant at this time? YES NO Date of your last gynecologic exam: Date of last Mammogram: Please place a check mark next to any of the following that apply to you: Irregular menses Vaginal bleeding between menstrual periods Excessive bleeding during menstrual periods Abnormal vaginal secretions History of Gastrointestinal and Liver Procedures/Radiologic Studies (please give the dates of any of the following procedures/studies you have completed): Hemmocult Cards: Flexible Sigmoidoscopy: Colonoscopy: CAT Scan: Pelvic Ultrasound: PET Scan: Upper GI Series (x-ray after swallowing barium): Upper Endoscopy (EGD): Barium Enema: Liver Biopsy: MRI: Other: History of Gastrointestinal, Digestive and Liver Diseases (please place a check mark next to those that apply to you): Colon Cancer Pancreatitis Removal of Appendix Colon Polyps Hemorrhoids Celiac Sprue Colon Surgery Ulcers Gallbladder Surgery Ulcerative Colitis Helicobacter pylori infection Hepatitis Hiatal Hernia Stomach Surgery What type? Crohn's Disease Stomach Cancer Other Liver Disease Diverticulosis Gallstones What type? Diverticulitis Barrett's esophagus Achalasia Please describe any other gastrointestinal, digestive, liver disease or surgery not listed above: Have you been vaccinated against Hepatitis A? YES NO If yes, please indicate date: Have you been vaccinated against Hepatitis B? YES NO If yes, please indicate date:

3 Page 3 of 5 Past Medical History (please place a check mark next to those that apply to you): Blood clotting disorder Diabetes Psoriasis Excessive bleeding during Thyroid disease Kidney Stones procedure or surgery Under active or Overactive? Kidney failure requiring Sleep apnea Asthma dialysis Taking blood thinners Emphysema Transplant of any organ Anemia Pneumonia Please specify: Blood transfusion Endometriosis Cancer Heart attack Ovarian cyst What type: Angina Fibromyalgia Leukemia or lymphoma Congestive heart failure Fainting AIDS Heart murmur Stroke Herpes Artificial heart valve Seizure disorder Mononucleosis Mitral valve prolapse Head injury Tuberculosis Rheumatic fever Migraine headaches Lyme disease High blood pressure Spine problems Lupus Elevated cholesterol Depression Gout Heart arrhythmia Bipolar disorder Arthritis What type? (i.e. atria fibrillation) Schizophrenia What type: Hip Replacement or other prosthesis? Please specify? Have you ever been tested for the AIDS virus? YES NO Have you received antibiotic prophylaxis for procedures, including dental? YES NO Please describe any other medical disorders not listed above: Please list any prior hospitalizations you have had: Date Reason for Hospitalization Please list any prior surgeries you have had (not previously listed): Date Reason for Surgery

4 Are you allergic to any medications? YES NO Page 4 of 5 If yes, please list them: Do you have any other allergies? YES NO If yes, please list them: Do you take aspirin? NO YES If yes, dose: How often do you take aspirin? (i.e. daily, 1x week, etc.) Do you take Advil, Aleve, Motrin or similar anti-inflammatory medication? NO YES If yes, name of medication: Dose: How often? (i.e. daily, 1x week, etc.) Do you take antacids or acid blocking medication such as Mylanta, Zantac, Pepcid, Prilosec or Prevacid? NO YES If yes, name of medication: Dose: How often? (i.e. daily, 1x week, etc.) Please provide the names and doses of the medications you are currently taking (including prescription, non-prescription, vitamins and herbal supplements): Name of Medication Dose Name of Medication Dose OTHER HISTORY Do you smoke cigarettes? YES NO If yes, how many cigarettes per day? If yes, how many years? Are you a former smoker? YES NO If yes, how many cigarettes per day? For how many years? When did you stop? Do you drink alcoholic beverages? YES NO If yes, how many drinks per day/week/month? (measured as 1 ounce scotch = 1 beer = 1 glass of wine) Occupation: Marital Status: Number of Children: Family History Gastrointestinal, digestive or liver disease Please list the relatives who have had the following disorders and age at which he/she was diagnosed: Colon Cancer: Ulcers: Colon Polyps: Helicobacter pylori infection: Ulcerative Colitis: Liver Disease: Crohn's Disease: Gallbladder Disease: Other gastrointestinal, digestive or liver disease not described above:

5 Your Family's General Medical History: Page 5 of 5 Mother Father Age Medical Problems Deceased? If yes, cause? Siblings Children Dietary History Please describe the foods you typically have for the following meals: Breakfast Lunch Dinner Snacks Food Beverage Do you have a history of milk or other food intolerance? Do any of your symptoms occur either during or shortly after meals? Do you chew gum or consume other sugar containing products on a regular basis? If yes, please describe what you consume and how often: