Please describe your reason for today s visit: What are you hoping to get out of today s visit? How long has this been going on?

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1 Date of Birth: Name: Patient History Form Reason for Visit Please describe your reason for today s visit: What are you hoping to get out of today s visit? How long has this been going on? Does anything make your condition worse: Please describe Does anything particular help with your condition: Please describe Medications/Allergies Please document any medications you are currently taking. Please check if NO current medications Name Dose (Strength) How Many? How Often? Example: Aspirin 81mg 1 tablet Daily Do you take aspirin? If yes, please enter above Do you take other blood thinners? If yes, please enter above Have you taken any steroids (i.e. prednisone or cortisone) within the last 6 months? If yes, what kind of steroid? Name: Dose: For how long? When was the last dose? Do you have any medication allergies? If yes, please list below: 1. What type of reaction? 2. What type of reaction? Are you allergic to latex? V15.07 What type of reaction? Have you ever had the Pneumonia Vaccine? Date: 1

2 Preferred pharmacy name: Pharmacy Phone: Pharmacy address: In the event of a medical emergency, who may we contact? Name: Relationship: Phone: Review of Systems Please check any symptoms you are currently experiencing. Constitutional Integumentary (Skin) Chills Fatigue or Weakness Fever Recent weight gain of 10 or more lbs. Recent unplanned weight loss of 10 or more lbs. Itching (pruritus) Rash Hearing/Eyes/Vision (HEENT) Neurological Loss of hearing / Diminished hearing Loss of vision / Change in vision Dizziness / Light headed Extremity numbness / Tingling Headaches Memory loss Seizures Respiratory Chronic or frequent coughing Shortness of breath Psychiatric (Mental Health) Anxiety Depression Cardiovascular Chest pain Irregular heartbeat (palpitations) Metabolic/Endocrine Cold intolerance Heat intolerance Excessive thirst or urination (polydipsia) Gastrointestinal Abdominal pain Blood in stools Change in stools Constipation Diarrhea Accidental Bowel Leakage (ABL) Loss of appetite Nausea Vomiting Musculoskeletal Back pain Joint pain Genitourinary Pain with urination (dysuria) Blood in urine (hematuria) Urinary incontinence (leakage of urine) Hematologic/Lymphatic (Bleeding) Easy bleeding Reproductive (Females) Painful intercourse (dyspareunia) 2

3 Problem List Please check any problem you have had or you are being treated for. Please check this box if NO current medical problems. Blood Problems Anemia Blood clots (DVT/ Embolism) V12.51 Bleeding disorder Clotting disorder HIV positive V08 Cardiac Vascular Angina (chest pain) Arrhythmia (heart rhythm problems) Atrial fibrillation Heart attack 412 Heart failure Hyperlipidemia: (high cholesterol) Hypertension: (high blood pressure) Malignant hyperthermia Peripheral vascular disease: (Blood vessel problems in legs) Cancer Anal cancer Bladder cancer Breast cancer Cervical cancer Colon cancer Kidney cancer Ovarian cancer Penile cancer Prostate cancer 185 Rectal cancer Small bowel cancer Stomach cancer Urinary tract cancer Cancer Continued Uterine (endometrial) cancer Vulva cancer Other cancer Eyes Glaucoma Vision impairment Endocrine Adrenal disease Diabetes Hyperthyroidism (high thyroid disease) Hypothyroidism (low thyroid disease) Gastrointestinal Anal / Rectal trauma / Injury Celiac disease (gluten sensitivity) Colorectal polyps V12.72 Crohn s disease Irritable bowel syndrome (IBS) Ulcerative colitis Leakage of stool (Incontinence) Infection Hepatitis type: V02.60 MRSA V02.54 VRE V02.59 Kidney/Urinary Poor kidney function Renal failure 586 Urinary incontinence (leakage of urine) Other medical problem not listed above: Mental Health Anxiety Depression 311 Musculoskeletal Arthritis Back problems Gout Pelvic fracture Neurological Multiple sclerosis 340 Neuropathy Seizures Spinal cord injury Stroke (Cerebrovascular accident) V12.54 Brief stroke (Transient ischemic attack - TIA) V12.54 Respiratory Asthma COPD 496 Sleep apnea Other: Female specific: Abnormal pap smears o Anus o Cervix o Vaginal Genital warts Male specific: Abnormal pap smear anus Enlarged Prostate Genital warts Females Only: Your Obstetric History (OBGYN Detail) Are you currently pregnant? Possible Number of pregnancies: G Number of live births: P Number of C-Sections: Number of vaginal deliveries: Did you have a tear/laceration during delivery? Which Pregnancy? Did you have an episiotomy during any delivery? Which Pregnancy? Was forcep extraction used for any delivery? Which Pregnancy? Was vacuum extraction used for any delivery? Which Pregnancy? Did you experience Accidental Bowel Leakage (ABL) after any delivery? Which Pregnancy? If yes, how long? If yes, did your accidental bowel leakage (ABL) resolve (stop)? Did you notice the passage of gas through your vagina after any delivery? Which Pregnancy? 3

4 Surgery/Procedures - Please check all that apply and indicate the year the surgery was performed. Please check this box if NO past surgeries. Abdominal Surgery Appendectomy (appendix) Cholecystectomy (gallbladder) Hernia repair Gastric bypass (weight loss surgery) Abdominoplasty (tummy tuck) Bowel Surgery Colectomy (Removal of a portion of large intestine / colon) Small bowel resection (Removal of a portion of small intestine) Colostomy Ileostomy stoma Closure of ileostomy or Colostomy Parks pouch (Ileoanal Reservoir) Rectal prolapse repair (Abdominal) Rectal prolapse repair (Anorectal) Bowel Incontinence Surgery Anal sphincter repair Sacral nerve stimulation Anal or Rectal Surgery Sphincterotomy (fissure surgery) Fistula surgery Rectovaginal fistula repair Hemorrhoid surgery Pilondal cyst surgery Drainage of abscess Transplant Surgery Heart Lung Kidney Liver Orthopedic Surgery Hip replacement Knee replacement Back surgery o Cervical o Lumbar o Thoracic Female Specific Surgery Breast augmentation Mastectomy Cervical procedure (LEEP/CONE) C-section Hysterectomy Abdominal Hysterectomy Vaginal Removal of tubes and ovaries Infertility surgery Rectocele / Enterocele repair Urinary incontinence procedures Bladder repair / Cystocele repair Sling Vaginal prolapse repair Male Specific Surgery Removal of prostate Prostate radiation Cardiac (heart)/vascular (blood vessels) Aortic aneurysm repair / Aortic bypass Cardiac pacemaker Defibrillator Heart stents Heart valve placement Coronary bypass (CABG) Miscellaneous Surgery Dental / Oral surgery Tonsillectomy Other Surgery Have you had any major problems with anesthesia? Have you had any excessive bleeding problems with surgery? Diagnostic Studies Please check all that apply and indicate location and date study was performed. Please check this box if NO diagnostic studies have ever been performed. Colonoscopy Location/Facility: Date: Flexible Sigmoidoscopy Location/Facility: Date: CT of Abdomen/Pelvis Location/Facility: Date: CT-PET Location/Facility: Date: Transit Time Study Location/Facility: Date: Mammogram (Females) Location/Facility: Date: Anal Pap (cytology) Location/Facility: Date: 4

5 Your Family History For any of your family members, please check all that apply. Please check this box if NO relevant family history. If yes, please indicate the family member and if that member was maternal (mother s side) or paternal (father s side). Family Member Maternal or Paternal Age Diagnosed Age Deceased Colon Cancer Rectal Cancer Celiac Disease Colon Polyps Crohn s Disease Ulcerative Colitis Cancer: Bile Duct /Gallbladder Cancer Bladder Cancer Brain Cancer Breast Cancer Endometrial Cancer Gastric (Stomach) Cancer Kidney Cancer Ovarian Cancer Small Intestine/ Small Bowel Cancer Uterine Cancer Other Cancer Type Factor V Leiden Deficiency Hemophilia Malignant Hyperthemia Von Willebrand s Disease Personal Habits / Social History Have you ever used tobacco? /never Formerly -- Age Quit: Smoking Tobacco Use (former and current): n-smoking Tobacco Use (former and current): Cigarette cigarettes/packs per day (circle one) Chewing units per day Cigarillo per day E-cig units per day Cigar per day Snuff units per day Pipe per day Do you consume alcohol? /Never Formerly (in the past) Type: Beer Wine Liquor How many drinks at a time? How often? Are you currently: Single Married Partnered Are you currently employed? Occupation: Have you ever used drugs? Formerly (in the past) Have you ever had anal sex? HIV Status: Negative Positive t Tested 5

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