Page 1 of 5 Modesto Gastroenterology Medical Corporation Magdy S. Elsakr, M.D. Board Certified Gastroenterologist 2336 Sylvan Avenue, Suite A, Modesto, CA 95355, Phone: 209-338-0292, Fax: 209-338-0298 Eva Rivera FNP, MSN, RN Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: tes: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more White Black or African American Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Unknown Ethnicity Hispanic or Latino t Hispanic or Latino Sex Male Female Other Preferred Language English Spanish; Castilian Contact Preference Cell Phone Home Phone Work Phone Portal Messages Allergies Patient has no known allergies Patient has no known drug allergies Latex Current Medications
Page 2 of 5 Name Dose How taken? Immunizations Flu vaccine Hep A, adult Hep B, adult Pneumonia Diagnostic Studies/Tests Colonoscopy EGD (Upper Endoscopy) Radiology Testing Past or Present Medical Conditions Colon polyps Colon cancer Rectal Cancer Uterine Cancer Hypertension Diabetes Mellitus Hepatitis C High cholesterol Ulcerative Colitis Crohns Disease Previous Procedures Blood Transfusions Procedure Procedure Family Medical History knowledge of family history family history of Colon cancer Colon Polyps Esophageal Cancer Stomach Cancer Health Status Deceased/At Age Cause of Death Diagnoses
Page 3 of 5 Colon Cancer Colon Polyps Stomach Cancer Esophageal Cancer Uterine Cancer Breast cancer Social History Occupation: Number of Children: Marital Status Single Married Divorced Separated Widowed Civil Union Unknown Other Alcohol Type Quantity Frequency Beers Wine Caffeine Coffee Tea Soda Other Tobacco Smoking Status Current every day smoker Smoker, current status unknown Current some day smoker Light tobacco smoker Former smoker Heavy tobacco smoker Never smoker Unknown if ever smoked Type Started Quit Quantity Frequency Cigarettes Cigar Smokeless Drug Use Marijuana Cocaine Other Exercise
Page 4 of 5 Review Of Systems Allergic/Immunologic HIV exposure persistent infections strong allergic reactions or urticaria Cardiovascular chest pain Heart Attack Heart Murmur High Blood Pressure High cholesterol irregular heart beat Leg Cramps palpitations Other Constitutional fatigue fever loss of appetite weight gain weight loss ENMT Loss of Hearing nose bleeds Ringing in Ears sore throat Endocrine excessive thirst hair loss heat intolerance Eyes Cataracts Glasses Glauoma loss of vision Gastrointestinal abdominal pain black stool change in bowel habits constipation diarrhea Difficulty Swallowing gas heartburn Hepatitis jaundice nausea rectal bleeding stomach cramps vomiting weight loss Genitourinary Blood in Urine frequent urination Painful urination Lack of bladder control kidney stones Testicular Pain Testicular Swelling Hematologic/Lymphatic bleeding gums or palpable lymph nodes easy bruising prolonged bleeding Integumentary allergies dryness hives itching Musculoskeletal arthritis back pain Osteoporosis Neurological Stroke TIA seizures fainting frequent headaches migraine Psychiatric anxiety depression Schizophrenia Suicidal Attempts panic attacks Respiratory asthma wheezing Cough blood Shortness of breath Sleep Apnea Pharmacy Name Address Phone Consent to Import Medication History I consent to obtaining a history of my medications purchased at pharmacies. Consent to Share Data
Page 5 of 5 I consent to having my medical and demographic information shared with other health care entities. Reminder Preference I would like to receive preventive care and follow up care reminders. Reviewed with Patient Parent Guardian t Present Signature Signature Date