JOHN MICHAEL ROACH, MD
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1 GASTROENTEROLOGY JOHN MICHAEL ROACH, MD 520 N. 4 TH AVE. PASCO, WA Phone: (509) Name: Date of Birth: First Middle (full) Last m/d/yr Primary care provider: Referring physician: Local Pharmacy: Mail Order Pharmacy: Name Location Brief Reason for Visit today: Medical History Please circle Y (Yes) or N (No) next to any of the medical conditions you experience or have been diagnosed with. If you circle Y (Yes), please answer any corresponding questions mentioned below. GERD / Reflux Y N Heartburn Y N Mid / upper abdominal pain Y N Indigestion Y N Difficulty swallowing Y N Gastrointestinal: (upper) 1) Do you notice worsening of these symptoms with any of the following: Red sauces (pizza, spaghetti, barbeque) Y N Citric juices (orange juice, lemonade) Y N Gluten products (wheat, rye, and barley) Y N Other: Diminished appetite Y N Unintentional weight loss Y N Nausea Y N Vomiting Y N Bloating / Belching / Gas Y N 2) Do you take medication(s) for these symptoms such antacids? Y N If yes, what medication(s) and dosage do you currently take? 3) Have you tried other medication(s) in the past for these symptoms? Y N If yes, please specify which medication(s), dosage, and approximate dates of use: 4) Have you ever had an endoscopy? Y N (If answered yes, please answer the following): When: Where: Provider:
2 Change in bowel habits Y N Diarrhea Y N Constipation Y N Rectal bleeding Y N Hemorrhoids Y N Gastrointestinal: (lower) Anal fissure Y N Diverticulosis Y N Diverticulitis Y N Colon polyps Y N Colon cancer Y N 1) Have you ever had a colonoscopy? Y N (If answered yes, please answer the following): When: Where: Provider: 2) Have you ever had colon surgery? Y N If yes, reason: 3) Do you notice a change in bowel habits (diarrhea, constipation, etc.) with the following: Dairy products (milk, cheese, yogurt) Y N Gluten products (wheat, rye, and barley) Y N Fatty foods (butter, cookies, fried foods) Y N Other: Abdominal pain Y N Location: Gastrointestinal (other): Gallbladder stones Y N Year diagnosed: 1) Have you had previous gallbladder surgery / removal? Y N If yes, what year? 2) Do you notice a worsening in abdominal pain after eating a high fat meal? Y N 3) Have you had imaging done for your gallbladder / abdomen in the last year? Y N If yes, what type of imaging (ultrasound, MRI, etc.) Facility performed at: Anxiety Y N Depression Y N Migraines Y N Anemia Y N Hypertension Y N Neurology: Seizures Y N Sleep disorder Y N Alcoholism Y N Cardiovascular: Heart attack Y N Heart disease Y N Drug use Y N Fibromyalgia Y N Stroke Y N High cholesterol Y N Respiratory Asthma Y N Sleep apnea Y N COPD Y N NEW PATIENT PAPEROWORK Page 2 of 5
3 Surgical History 1) Have you ever had joint replacement surgery? (examples: knee, hip, heart valve) Y N If yes, what joint(s) did you have replaced? (Please indicate right or left if applicable): 2) Please list all surgeries in the spaces provided. Please do not exclude childhood surgeries or minor surgeries. Family History Please list all family members (parents, siblings, grandparents, aunts, uncles, children, etc.) that have been diagnosed with the following. Please include yourself if you have been diagnosed with the following: Colon cancer: Breast cancer: Ovarian cancer: Uterine cancer: Cervical cancer: Colon polyps: Crohn s disease: Ulcerative colitis: Celiac Disease: Gallbladder disease: Social History 1) Do you drink alcohol? Y N Former a) Type: Beer Wine Hard Liquor b) How many servings on average are consumed: Daily? Weekly? Monthly? Yearly? 2) Do you drink caffeine? Y N a) Type: Coffee Tea Soda Energy drinks b) How many servings on average are consumed: Daily? Weekly? Monthly? 3) Do you use tobacco products? Y N Former a) Type: Cigarettes Chewing tobacco Cigars Hookah b) How many packs per day do you OR did you smoke? How long (months/years): c) What year did you quit? (leave blank if not applicable) 4) Do you currently take any anti-inflammatory products (Aspirin, Ibuprofen, Aleve, etc.) Y N a) Name of medication(s) and dosage: b) How many tablets do you take on average: Daily? Weekly? Monthly? Yearly? NEW PATIENT PAPEROWORK Page 3 of 5
4 Review of Systems Please indicate any new or worsening symptoms that you are currently experiencing or have experienced in the last 4 weeks by checking the corresponding box. General Fever Chills Fatigue Anorexia Head and Face Face pain ENT Blurred vision Sore throat Hoarseness Cardiovascular Chest pain Palpitations Lightheadedness Respiratory Shortness of breath Dry cough Productive cough o Clear sputum o Colored sputum Vomiting Blood Gastrointestinal Abdominal pain Abdominal bloating Abdominal cramping Nausea Vomiting Diarrhea Constipation Rectal bleeding (bright red blood) Dark stools (melena) Genitourinary Painful urination (dysuria) Urinary frequency Urinary urgency Blood in urine (hematuria) Musculoskeletal Diffuse joint pain Muscle aches (generalized) Back pain Joint swelling Neurological Headache Confusion Dizziness Tingling Psychiatric Difficulty sleeping Anxiety Depression Endocrine Night sweats Muscle weakness Hematologic and Lymphatic Swollen glands Easy bleeding Jaundice NEW PATIENT PAPEROWORK Page 4 of 5
5 Medication ALLERGIES Reaction MEDICATION LIST Please list all prescription and non-prescription medicines and supplements you take regularly or occasionally. Include medications discontinued or changed in the past 2 weeks. This information is for your safety to avoid drug-drug interactions. START DATE NAME OF MEDICATION DOSAGE AND DIRECTIONS REASON FOR TAKING DATE STOPPED NEW PATIENT PAPEROWORK Page 5 of 5
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
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
Patient Interview Form
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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.
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT
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Modesto Gastroenterology Medical Corporation
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Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?
Patient Interview Form
Page 1 of 7 Patient Interview Form UNIVERSITY GASTROENTEROLOGY 33 Staniford Street, Providence, RI 02905 Phone 401-421-8800 Fax 401-421-2492 Patient Information First Name: MRN: Age: Last Name: Date Of
Today s Date: Pt Initials: PATIENT INFORMATION. First Name: Last Name: Middle Name: Date of Birth: Social Security #: Preferred Language:
PATIENT INFORMATION First Name: Last Name: Middle Name: Suffix: Nickname: Male Female Date of Birth: Social Security #: Preferred Language: Race: Asian Native Hawaiian Other Pacific Islander Black / African
New Patient Pain Evaluation
New Patient Pain Evaluation Name: Date: Using the following symbols, mark the areas of the body diagrams which are affected by your pain: \\ = Stabbing * = Electrical X = Aching N = Numbness 0 = Dull S
MEDICAL HISTORY (To be filled in by patient)
MEDICAL HISTORY Reason for Visit or Chief Complaint: Referred By: Present Illness: (To be filled in by Physician) I. Have you had any reactions, allergies or bad effects from any of the following: Serum
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
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.