Inflammatory Bowel Disease Medical Exam Questionnaire

Transcription

1 Patient Name: MR: Date: Name DOB / / Age Marital Status Race Gender M / F Height Present Weight Usual Weight Insurance Managed Care Self referral Yes No Yes No Yes No Primary Care Physician Referring Physician (if different from PCP) Pharmacy Name Address City Phone( ) ( ) Phone( ) Fax( ) How would you rate your present health? Excellent Good Fair What type of Inflammatory Bowel Disease have you been diagnosed with? Poor a. Crohn s disease b. Ulcerative Colitis c. Indeterminate Colitis d. Collagenous Colitis e. Lymphocytic Colitis f. Other How old were you when you were diagnosed? How old were you when you began having symptoms? Have you ever had an operation for the Inflammatory Bowel Disease? Yes If yes, please indicate the type of surgery and the date(s) you had surgery: Bowel Resection Ostomy Abscess Drainage Stricture Repair (stricturoplasty) No Complete colectomy with Ileal pouch anal anastomosis Appendectomy Perianal surgery (fistula repair, seton placement, sphincterectomy, abscess drainage) Have you had any other operations? Yes No If yes, please list the type of surgery, approximate year, hospital, and physician(s) name(s)

2 Please list illness(es) that did not require an operation for which you were hospitalized. (Give dates, hospital, city and physician in charge.) Have you ever had Pouchitis? Yes No Don t Know N/A Do you have any fistulas communicating from the GI tract to the skin or some other area of the body? Yes No Don t Know Are you currently taking medications? Yes No (Include any OTC * drugs, especially vitamins or herbal preparations. If yes, please list with dosages.) * OTC = Over-The-Counter medications prescription is not required Do you have any allergies to medications? (if yes, list drug and the reaction it caused) Have you ever been on steroids? Yes No If yes, have you been on: Oral steroids (prednisone, budesonide, Entocort) Date last taken IV steroids Date last taken Steroid enemas or suppositories (Proctofoam, etc.) Date last used Have you ever taken any of these medications? If yes, what dose were you taking and why did you stop taking it (nausea, other symptoms, wasn t working, couldn t afford it, etc.): Medication Yes/No Dose Used Did it help your IBD? (Yes/No) Reason for Stopping Mesalamine 6-MP Imuran Methotrexate Cyclosporine Sirolimus/Tacrolimus Remicade Humira Cimzia Tysabri Other study/experimental medications

3 Have you ever been diagnosed with a blood clot in your leg or your lungs? Yes No If yes, when? When was your last colonoscopy? Have you ever had a Bone Densitometry Test (DEXA scan)? Yes No If yes, when? What was the result? Osteoporosis Osteopenia Normal I don t know When was the last time that you had an eye examination? When was the last time you saw your dentist? Do you smoke? Yes No Cigarettes Pipe Cigar If yes, how many packs per day? For how many years? If no, did you ever smoke? Yes No If yes, when did you quit? Do you drink alcohol? Yes No Hard liquor Beer Wine If yes, how many drinks do you have in a typical day? Have you ever: Had Rheumatic Fever Had Chicken Pox Received a blood transfusion Used intravenous drugs Been tested for Hepatitis A Been tested for Hepatitis B Been tested for Hepatitis C Been tested for HIV Been tested for Tuberculosis Yes No Do not know Have you received any of the following immunizations? Hepatitis A Hepatitis B Tetanus Pneumovax Annual Flu Vaccine Meningococcal Vaccine Zoster Vaccine Varicella Vaccine Human Papillomavirus Vaccine Yes No Do not know Date

4 Women Only Are you sexually active? Yes No Form of birth control: Have you ever had a Pap smear? Yes No Don t know When was your last Pap smear? Date Have you ever had a sexually transmitted disease? Yes No Don t know Have you ever had genital warts? Yes No Don t know Have you ever had an abnormal pap smear result? Yes No Don t know Have you ever had a mammogram? Yes No Don t know Abnormal mammogram Yes No Don t know Number of Pregnancies Number of miscarriages Have you taken oral contraceptives? Yes No Don t know Men Only Are you sexually active? Yes No Form of birth control: Have you ever had a sexually transmitted disease? Yes No Don t know Have you ever had genital warts? Yes No Don t know FAMILY HISTORY Living? Age or age at death Present health or cause of death Father Yes No Mother Yes No Spouse Yes No Are you married or have a significant other? Yes No Brothers # living Health Problems? # dead Health Problems? Sisters # living Health Problems? # dead Health Problems? Children living Age(s) Health Problems? Children dead Age(s) Health Problems? Please circle illness(es) which have occurred in any of your blood relatives: Diabetes Cancer Easy Bleeding Kidney disease Tuberculosis Heart trouble Stroke High blood pressure Nervous illness Allergies

5 REVIEW OF SYSTEMS Mark the appropriate response if any of the following has been a problem recently: Weight loss Weight gain Fatigue Rashes Itching Change in skin color History of anemia Easy bruising or bleeding Change in vision Do you wear glasses History of glaucoma Ear problems Nose bleeds Sinus problems Dentures Frequent colds Shortness of breath Wheezing Chronic cough Bloody phlegm Pneumonia Bronchitis Tuberculosis Asthma Recent chest x-ray Swelling of legs Abnormal heart beats Chest pain Heart murmur Heart Attack Abnormal EKG Neurologic disease Seizures Frequent headaches History of stroke Yes No Yes No Anxiety attacks Nervous breakdown Depression Nausea Vomiting Diarrhea Constipation Abdominal pain Change in bowels Excessive gas Rectal bleeding Gallbladder disease Hemorrhoids Ulcer disease Hepatitis Polyps in colon Colitis Excessive urination Burning on urination Difficulty urinating Urinary hesitancy Urinary dribbling Urinary frequency Urinary infections Kidney stones Venereal disease Air passage on urination Joint pains Arthritis Joint swelling Muscle pain Leg cramps Thyroid disease Diabetes mellitus High cholesterol