Patient Interview Form

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1 Page 1 of 5 Telephone: Fax: Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Race Select one or more White Unknown Black or African American Asian Prohibited by state law American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Ethnicity Hispanic or Latino t Hispanic or Latino Prohibited by state law Preferred Language Consent to Share Data I consent to having my medical and demographic information shared with other health care entities. Reminder Preference I would like to receive preventive care and follow up care reminders. Pharmacy Name Address Phone Consent to Import Medication History I consent to obtaining a history of my medications purchased at pharmacies.

2 Page 2 of 5 Current Medications Name Dose How taken? Allergies Patient has no known allergies Patient has no known drug allergies Contrast Iodine Latex Sulfa Penicillins Adhesive Tape Antibiotics Eggs Soy Past or Present Medical Conditions Diagnosed GI Conditions n-gastrointestinal Conditions Celiac Disease Hiatal Hernia Anal Fissure Colon Polyps Pancreatitis Hemorrhoids Gastric Ulcer GERD Diverticulosis Diverticulitis Hepatitis A Hepatitis B Hepatitis C Hepatic Failure Crohn's Disease Alcohol Abuse Irritable Bowel Syndrome Esophageal Stricture Disorder of Gallbladder Congestive Heart Failure Intestinal Obstruction Chronic Constipation Gastrointestinal Bleeding Yellow or Jaundiced Color Ulcerative Colitis Clostridium Difficile Infection Barrett's Esophagus Exposure to HIV Asthma Lupus Seizure Disorder Stroke Multiple Sclerosis Helicobacter Pylori/H. Pylori Antibiotic Treatment in Past 3 Months Heart Attack Heart Disease Blood Clots Anemia Thyroid Disease HIV Positive Arthritis Hypertension Fibromyalgia Kidney Disease C.O.P.D. Abnormal Heartbeat Dyslipidemia Type 1 Diabetes Mellitus Type 2 Diabetes Mellitus Cardiac Arrhythmia High Cholesterol Cancer Esophagus Ovaries Skin Stomach Lungs Colon Rectum Prostate Uterus Leukemia Pancreas Breast Bladder Mouth/Throat

3 Page 3 of 5 Diagnostic Studies/Tests Colonoscopy Flexible Sigmoidoscopy EGD ERCP EUS CT Abdomen/Pelvis Abdominal Ultrasound MRI Abdomen/Pelvis MRCP Previous Procedures Appendectomy Colectomy Gallbladder Removal Hiatal Hernia Repair Shoulder Lysis of Adhesions Cosmetic Coronary Artery Bypass Graft (CABG) Hysterectomy - Abdominal TURP Hip Defibrillator Placement Transplant - Renal Bilateral Knee Hernia Repair - Umbilical Transplant - Liver Heart Valve Back Breast Pacemaker Insertion Cesarean Section Craniotomy Cataract Social History Occupation: Number of Children: Marital Status Single Married Divorced Separated Widowed Civil Union Other Alcohol Daily Weekly Socially Previous Caffeine In the Past 1 cup daily 2-3 cups daily More than 5 Occasional Drug Use Marijuana IV Cocaine Previous Drug Use Other Tobacco Smoking Status Current every day smoker Current some day smoker Former smoker Never smoker Smoker, current status unknown Light tobacco smoker Heavy tobacco smoker Unknown if ever smoked

4 Page 4 of 5 Family Medical History knowledge of family history family history of Celiac sprue Colon cancer Colon polyps Crohn's disease Liver disease Stomach cancer Ulcerative Colitis / IBD Diagnoses Colorectal Cancer Colon Polyps Irritable Bowel Syndrome Liver Disease Ulcerative Colitis Crohn's Disease Celiac Disease Alcohol Abuse Hemochromatosis Autoimmune Hepatitis Liver Failure Ulcer Disease Gallstone Hepatitis B Hepatitis C Stomach Cancer Breast Cancer Uterine Cancer Ovarian Cancer Lung Cancer Skin Cancer Leukemia Pancreatic Cancer Immunizations Flu vaccine PCV7 (Pneumonia)

5 Page 5 of 5 Review Of Systems Cardiovascular chest pain Swelling of Extremeties syncope Respiratory cough dyspnea excessive phlegm coughing up blood wheezing Constitutional fatigue fever loss of appetite weight loss night sweats ENMT ear pain nasal obstruction nose bleeds sore throat hearing loss Endocrine excessive thirst heat intolerance Eyes loss of vision Gastrointestinal abdominal pain abdominal swelling change in bowel habits constipation diarrhea gas/flatulence heartburn nausea rectal bleeding stomach cramps vomiting difficulty swallowing food intolerance vomiting blood black stool pain with bowel movement incontinence of stool blood in stool Genitourinary dark urine dysuria frequent urination hematuria Integumentary hives itching jaundice rashes Musculoskeletal back pain joint pain muscle weakness stiffness Neurological dizziness fainting frequent headaches migraine numbness or tingling memory loss Psychiatric anxiety depression hallucinations nervousness panic attacks paranoia Reviewed with Patient Parent Guardian t Present Signature Signature Date

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