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Transcription:

Acct #: Patient History Form Please answer ALL questions by filling out the appropriate box(es). Name: Gender: M F Primary Care Provider: DOB: Today s Date: Referring Provider (if different from PCP): Chief Complaint-Primary reason for today s visit: Length of symptoms: Have you ever been seen by a GI doctor before? No Yes If yes, please list provider(s): Do you need special accommodations for your exam? No Yes If yes, please describe: Preventative Care Colonoscopy Flexible Sigmoidoscopy Fecal Blood Testing Flu Vaccine Pneumonia Vaccine PCV13 (Prevnar) Page 1 of 6

Your Medical History Please indicate whether you have or have had any of the following by filling in the appropriate box(es). NONE Respiratory Genitourinary/GYN Cancer Cardiovascular Asthma Kidney disease Anal Arrhythmia Emphysema/COPD Pelvic organ prolapse Breast Congestive heart failure Sleep apnea Sexual abuse Cervical Deep vein thrombosis Uterine/Cervical disease Colon Heart attack Gastrointestinal Esophageal High blood pressure Barrett s esophagus Ear Nose Throat Head and neck High cholesterol Colon polyp Allergic rhinitis Liver Peripheral artery Crohn s disease Nasal/Facial fracture Ovary disease Diverticulitis Pancreas Pulmonary embolus Gallbladder disease Hematologic/Lymphatic Prostate GERD (reflux) Anemia Rectal Rheumatologic Hepatitis Bleeding disorders Stomach Other arthritis Irritable bowel syndrome Blood transfusion Uterine (endometrial) Rheumatoid arthritis Liver disease Coagulation disorders Other cancer Pancreatitis Psychological Ulcerative colitis Neurological Infections Alcohol dependence Ulcers Migraine headache HIV/AIDS Anxiety Seizure disorder Tuberculosis Bipolar Endocrine Stroke or TIA Depression Diabetes Drug dependence Osteoporosis Eating disorder Thyroid disorders Other mental illness Other disorder(s) not listed above: Page 2 of 6

Past Surgical History Please list any previous surgeries in the box below. NONE Have you ever had general anesthesia (breathing tube)? No Yes If yes, were there complications? No Yes (Please describe) Have you ever had IV conscious sedation (no breathing tube)? No Yes If yes, were there complications? No Yes (Please describe) Procedures Please indicate if you have had any of the following procedures: Type Date Facility Bone Density Scan CT Scan MRI Scan Ultrasound Upper Endoscopy (EGD) Current Medications/Supplements/Vitamins What pharmacy do you use? Do you currently take Coumadin (warfarin), Aspirin, Plavix, Pradaxa, Eliquis, or other blood thinners? No Do you take any herbal supplements? No Yes Yes Provide a detailed list of medications/supplements/vitamins with doses, OR bring medication bottles to your appointment. Medication Dose How often taken Page 3 of 6

Allergies Please list any medication allergies (lidocaine, penicillin, sulfa, etc.). Medication Reaction(s) Other Reaction (describe) Rash Difficulty Breathing Do you have an allergy to IV Contrast? No Yes Do you have an allergy to Lidocaine? No Yes Do you have an allergy to Latex? No Yes Social History Occupation (current/former): Currently Employed? Full Time Part Time No Marital status? Single Married Partnered Separated/Divorced Widowed Children: # Living Ages # Deceased Ages Patient Habits Caffeine Do you drink caffeinated beverages? No Yes If yes, how many per day? Tobacco/Nicotine Smoking status: Current every day smoker Current some day smoker Light tobacco smoker Heavy tobacco smoker Former Never If current or former smoker, how many packs per day? What year did you start? If former smoker, what year did you quit? Alcohol Do you currently drink alcohol? No Yes If yes, on average, how many drinks per week? Page 4 of 6

Marijuana/Recreational Drugs Have you ever used marijuana, IV or other recreational drugs? No Yes If yes, what type? Marijuana Crack/Cocaine Methamphetamines Heroin Other (please specify) Have you ever used by IV, by needle, or by inhaling up your nose? No Yes What year did you start? Have you quit? No Yes If yes, what year did you quit? Family History Are you adopted? No Yes Don t know Father: Mother: Alive Deceased Don t know Alive Deceased Don t know Does anyone in your family have a history of any of the following? Mother Father Sister Brother Daughter Son NONE Cancer Breast cancer Colon or rectum cancer Esophageal cancer Ovarian cancer Pancreatic cancer Stomach cancer Thyroid cancer Uterine cancer Other cancer Gastrointestinal Celiac disease Colon polyps Crohn s Gallbladder disease Irritable bowel syndrome Liver disease Ulcerative colitis Page 5 of 6

Review of Systems Fill in the box if you have had one of these symptoms in the LAST SIX MONTHS. NONE General Cardiovascular Urinary Fatigue Ankle/leg/foot swelling Blood in urine Fever Chest pain Problems urinating Loss of appetite Irregular heart beat Unintentional weight loss Skin Gastrointestinal Itching Neurological Abdominal pain Rash/sores Dizziness Black tarry stools Headache Bloating Musculoskeletal Memory loss Blood in stool Back pain Seizures Change in bowel habits Joint pain Sleep difficulty Constipation Joint swelling Diarrhea Eyes Difficulty swallowing Endocrine Blurring Heartburn Cold intolerance Vision changes Jaundice Heat intolerance Mucus in stool Ears Nose Throat Nausea Psychological Dental problems Regurgitation Anxious or nervous Hoarseness Painful swallowing Sad most of the time Mouth sores Vomiting Postnasal drainage Sinus pressure or pain Hematologic/Lymphatic Bleeding problems Respiratory Easy bruising Cough Enlarged lymph nodes Shortness of breath Night sweats Wheezing Other symptoms not listed above: Patient Signature: Date: Page 6 of 6

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