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Transcription:

Page 1 of 7 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Age: Contact Preference Email Cell phone Telephone call- Work Telephone call - Home Patient Portal Email Please check one as your preferred email for communications Personal: Work: Preferred Language Chinese English Japanese Korean Samoan Spanish; Castilian Tagalog Tonga (Tonga Islands) Vietnamese 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 Not Hispanic or Latino Sex Male Female Other 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

Page 2 of 7 Social History Occupation: Number of Children: Marital Status Single Married Divorced Separated Widowed Civil Union Unknown Other Alcohol Type Quantity Frequency Rarely Times / year Occasionally Moderately Daily Times / week Times / day Caffeine Daily Occasionally 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 Drug Use Type Quantity Frequency Recreational IV or intranasal drugs Exercise Type Occasional Regular Frequency Times / week

Page 3 of 7 Diagnostic Studies/Tests EGD Colonoscopy Flexible Sigmoidoscopy ERCP EUS Abdominal Ultrasound CT Abdomen/Pelvis MRI Abdomen/Pelvis Mammogram Previous Procedures Abdominal aortic aneurysm (AAA) repair Appendectomy Back Surgery Bariatric Surgery Bilateral Tubal Ligation (BTL) Breast Surgery Cardiac Cath - with stent placement Cholecystectomy Colon resection/ Colectomy Coronary Artery Bypass Graft (CABG) D & C Defibrillator Placement Exploratory Laparoscopy Fundoplication - Nissen (Acid Reflux) Heart valve replacement Hemorrhoid banding Hemorrhoidectomy Hysterectomy Joint Replacement Pacemaker Insertion PEG tube placement Small Bowel Resection - Segmental Whipple Procedure (Pancreaticoduodenectomy) Past or Present Medical Conditions Cardiology Angina Anticoagulation Therapy Arrhythmia Atrial Fibrillation Brain Aneurysm Congestive Heart Failure Coronary Artery Stents Coronary Artery Disease Defibrillator Heart Attack Heart Murmurs Hyperlipidemia Hypertension Mitral Valve Prolapse/MR Myocardial infarction Pacemaker Palpitations Stroke Transient Ischemic Attack Vascular Disease HIV infection Gastroenterology Barrett's Esophagus Celiac Disease Colon cancer Colon polyp Crohn's Disease Diverticulitis Diverticulosis Gastroesophageal Reflux Disease (GERD) Gastric Ulcer Gastritis H. Pylori Infection Hemorrhoids

Page 4 of 7 Irritable Bowel Syndrome Iron Deficiency Anemia Ulcer Disease Ulcerative Colitis Hepatology Cirrhosis Elevated Liver Function Test Fatty Liver Gallstones Hepatitis A Hepatitis B Hepatitis C Pancreatitis Pulmonology Asthma Blood Clots C.O.P.D. Emphysema Sleep apnea Wheezing Other Anxiety disorder Arthritis Bipolar disorder Breast cancer Body piercings Cataracts Carpal Tunnel Syndrome Current pregnancy Depression Diabetes Mellitus, Insulin Dependent (Type 1) Diabetes Mellitus, Non- Insulin Dependent (Type 2) Fibrositis / Fibromyalgia Gout Hematuria Hypothyroidism Kidney disease Kidney stones Lung cancer Migraines Obesity Osteoporosis Prostate Cancer Psoriasis Renal Failure Seizures Skin Cancer Tattoos Other cancers:

Page 5 of 7 Family Medical History No knowledge of family history No family history of Anesthesia reactions Celiac sprue Colon cancer Colon polyps Crohn's disease Liver disease Stomach cancer Ulcerative Colitis / IBD Diagnoses Anesthesia reactions Celiac disease Colon cancer Colon polyps Crohn's disease Gallbladder disease Liver disease Stomach cancer Ulcerative colitis

Page 6 of 7 Current Medications Name Dose How taken? Allergies Patient has no known allergies Patient has no known drug allergies Adhesive Tape Codeine Sulfate Erythromycin Penicillins Propofol Analogues IV Dye, Iodine And Iodide Containing Products Latex Soy Eggs Shellfish Immunizations Flu vaccine Pneumovax Hep A Hep B Pharmacy Name Address Phone Consent to Import Medication History I consent to obtaining a history of my medications purchased at pharmacies. Yes No Reviewed with Patient Parent Guardian Not Present Signature Signature Date

Page 7 of 7 Review Of Systems Allergic/Immunologic HIV exposure persistent infections strong allergic reactions or urticaria Cardiovascular chest pain dyspnea with exercise irregular heart beat orthopnea palpitations peripheral edema syncope Constitutional fatigue fever loss of appetite malaise sweats weight gain weight loss ENMT difficulty swallowing dizziness ear pain nasal obstruction nose bleeds sore throat hearing loss Endocrine excessive thirst hair loss heat intolerance Eyes double vision loss of vision photophobia 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 Musculoskeletal arthritis back pain gout joint deformity joint pain muscle weakness stiffness Neurological dizziness fainting frequent headaches migraine numbness or tingling seizures tremors vertigo memory loss Psychiatric anxiety depression difficulty sleeping hallucinations nervousness panic attacks paranoia Respiratory asthma cough dyspnea excessive sputum coughing up blood shortness of breath with exercise wheezing

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