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Transcription:

Page 1 of 6 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more White Unknown Black or African American Patient declines Asian Prohibited by state law American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Ethnicity Hispanic or Latino Not Hispanic or Latino Patient declines Prohibited by state law Sex Male Female Other Preferred Language Chinese English Patient declines Contact Preference Letter Email Cell phone Telephone call- Work Patient declines Telephone call - Home Pharmacy Name Address Phone Allergies Patient has no known allergies Patient has no known drug allergies

Page 2 of 6 Latex Eggs Peanuts Penicillins Iv Dye, Iodine Containing Soy Diary Current Medications Name Dose How taken? Immunizations Flu vaccine Hep A Hep B Pneumovax TB skin test Diagnostic Studies/Tests Colonoscopy EGD ERCP Stool Test CT Abdomen/Pelvis Abdominal Ultrasound Capsule Endoscopy MRI Abdomen/Pelvis Breath Test (Urease - H.Pylori) Past or Present Medical Conditions Gastroenterology/Hepatology Anemia Barrett's Esophagus Bowel Obstruction Crohn's Disease Diverticulitis Esophageal Stricture Fatty Liver Gallbladder Disease GERD H. Pylori Hemorrhoids Hiatal Hernia Inflammatory Bowel Disease Irritable Bowel Syndrome Ulcerative Colitis Gastric Cancer Colon cancer Colon polyp history Liver Cancer Intestinal Metaplasia Cardiology Atrial Fibrillation Coronary Heart Disease Deep Vein Thrombosis Valvular heart disease Endocarditis Myocardial infarction Congestive Heart Failure High blood pressure Coronary Artery Stents Pacemaker Pulmonology Asthma Emphysema Sleep apnea

Page 3 of 6 Other Arthritis Body piercings Diabetes HIV Hyperthyroidism Hypothyroidism Kidney disease Seizures Tattoos Previous Procedures Appendectomy Cardiac Cath - with stent placement Defibrillator Placement Hysterectomy Gastric Bypass Pacemaker Insertion Cholecystectomy Colon resection Coronary Artery Bypass Graft (CABG) Gastric Lap Band Small Bowel Resection Hemorrhoid banding Tubal Ligation Hemorrhoidectomy Social History Occupation: Number of Children: Marital Status Single Married Divorced Separated Widowed Civil Union Unknown Other Alcohol Type Quantity Number Frequency Less than 7 per week More than 7 per week Caffeine Coffee Tea Soda Tobacco Smoking Status Current every day smoker Current some day smoker Former smoker Never smoker Smoker, current status unknown Light tobacco smoker Heavy tobacco smoker Unknown if ever smoked Type Started Quit Quantity Frequency Cigarettes Cigar Chewing Tobacco Drug Use Type Quantity Number Frequency IV or intranasal drugs Times / month Recreational Times / month Exercise

Page 4 of 6 Regular exercise Occasional exercise Family Medical History No knowledge of family history No family history of Cirrhosis Colon cancer Liver cancer Stomach cancer Diagnoses Liver cancer Colon cancer Stomach Cancer Cirrhosis

Page 5 of 6 Review Of Systems Allergic/Immunologic HIV exposure persistent infections strong allergic reactions or urticaria urticaria hay fever Cardiovascular chest pain dyspnea with exercise irregular heart beat orthopnea palpitations peripheral edema syncope dyspnea on exertion Constitutional fatigue fever loss of appetite malaise sweats weight gain weight loss chills ENMT difficulty swallowing dizziness ear pain nasal obstruction nose bleeds sore throat hearing loss sleep apnea URI Endocrine excessive thirst hair loss heat intolerance cold intolerance polydipsia polyphagia polyuria weight change Eyes double vision loss of vision photophobia blurring diplopia irritation discharge eye pain glaucoma cataracts Gastrointestinal abdominal pain abdominal swelling change in bowel habits constipation diarrhea gas heartburn jaundice nausea rectal bleeding stomach cramps vomiting difficulty swallowing Genitourinary dark urine decrease in urine flow dysuria frequent urinary infections frequent urination hematuria impotence nocturia urethral discharge or incontinence Hematologic/Lymphatic bleeding gums or palpable lymph nodes easy bruising prolonged bleeding Integumentary allergies dryness hives itching jaundice lesions rashes oncomycosis Musculoskeletal arthritis back pain gout joint deformity joint pain muscle weakness stiffness neck pain joint swelling muscle cramps Neurological dizziness fainting frequent headaches migraine numbness or tingling seizures tremors vertigo memory loss Psychiatric anxiety depression difficulty sleeping hallucinations nervousness panic attacks paranoia memory loss mental disturbance suicidal ideation insomnia Respiratory asthma cough dyspnea excessive sputum coughing up blood shortness of breath with exercise wheezing

Page 6 of 6 Consent to Import Medication History I consent to obtaining a history of my medications purchased at pharmacies. Yes No Consent to Share Data I consent to having my medical and demographic information shared with other health care entities. Yes No Reminder Preference I would like to receive preventive care and follow up care reminders. Yes No Reviewed with Patient Parent Guardian Not Present Signature Signature Date

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