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Transcription:

GASTROINTESTINAL & MINIMALLY INVASIVE SURGERY HEALTH HISTORY QUESTIONNAIRE Date Patient Name _ Date of Birth Age Daytime phone ( ) Other phone ( ) Email How did you hear about us? My doctor Yellow pages News ad Radio/TV Friend/family Web site Other The American Cancer Society recommends colon cancer screening for persons over the age of 50. During your visit today, would you like to discuss a screening colonoscopy with your surgeon? No Yes Physicians Referring Physician Primary Care Physician Surgeon Oncologist GI Physician Other MD Medications - Please list your current medications and doses (include over-the-counter medications & supplements, i.e. vitamins, herbals, aspirin, etc.) Name of Medication Strength Frequency

Allergies Do you have any allergies to medications? NO YES If YES, please list the drugs and type of reaction: Medical History list any past/current problems and/or illnesses Examples: Diabetes, High Cholesterol, Hyperthyroidism or Heart Disease Problem Surgical History Examples: Appendectomy or Colon Resection Surgery When Where (Hospital) Any Complications? Procedures Please indicate if you have had any of the following procedures. NO Y ES Colonoscopy CAT scan Endoscopic Ultrasound (EUS) PET scan ph & Motility studies Other: Other: 2

Medical Conditions Mark the conditions below indicating what you have NOW and what you have had in the PAST. NO YES, YES, Condition in the Currently How long? Comments? past Active General Weight loss Fatigue or tiredness Iritis (inflammation of eyes) Blindness Mouth ulcers Heart Chest pain or angina Myocardial infarction (heart attack) Palpitation, arrhythmias, pacemaker Hypertension Stroke Claudication (poor blood flow to legs) Blood clots in legs Or lungs (pulmonary embolism) Lungs Asthma or emphysema Pneumonia Shortness of breath Chronic cough, sputum Intestines Nausea Vomiting Constipation Diarrhea Bloody or painful bowel movements Ulcer of stomach or duodenum (small intestine) Gastritis (inflammation of stomach) Diagnosis of GERD Abdominal pain When? Where? Does it move? What makes it worse? What makes it better? Disease of pancreas Gallbladder Disease / Stones Colon or Rectal Cancer Inflammatory bowel disease / Crohn s disease or ulcerative colitis Diverticulitis 3

NO YES, YES, Condition in the Currently How long? Comments? past Active Liver Jaundice Cirrhosis Hepatitis Kidney Kidney disease or stones Urinary or prostate problems Impotence (inability to have an erection) Bladder infections Endocrine Diabetes Thyroid problems Taken steroid (i.e. Prednisone) Previous organ transplant Muscles Muscle pain or injury Arthritis or bone pain Neurological illness Psychiatric illness Nerves Numbness Weakness Changes in vision Vascular Poor wound healing Cramping Bleeding disorder/easy bleeding or bruising Previous blood transfusion Anemia Taking a blood thinner (Coumadin or Plavix) Aspirin, NSAIDS (ibuprofen) or arthritis medications in last 7 days Testicular Testicular pain Testicular swelling Gynecological Menstrual cycle pain Abnormal menstrual bleeding Date of last menstrual period Date or last pregnancy # of vaginal deliveries # episiotomies # pregnancies 4

Family Medical History Has anyone in your family had the following conditions? N O YES Relation to you? Colon cancer Rectal cancer Colon and/or rectal polyps Uterine cancer Ovarian cancer Inflammatory bowel disease Heart Disease Stroke Other family history (Examples: mother with breast cancer, sister with heart disease) Family member Disease Social History NO YES Do you currently smoke cigarettes? Packs/day Have you ever smoked? Year you quit Do you drink alcohol? Drinks/week Have you ever been treated for alcoholism? Have you ever used intravenous drugs? Are you currently employed? Occupation Do you have children? Do you exercise frequently? Type and Frequency What is your marital status? Single Married / Partnered Divorced Widowed Other comments? Patient Signature Date Reviewed by MD Date Entered to EMR by Date 5

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