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Transcription:

Telephone: 703-698-8960 Fax: 703-828-0961 www.myganv.com Patient Interview Form Patient Information First Name: Last Name: Date Of Birth: Age: Height: Weight: Race Select one or more White Unknown Black or African American Patient declines to specify 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 to specify Prohibited by state law Preferred Language Arabic English Hindi Korean Spanish; Castilian Patient declines to specify 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 Pharmacy Name Address Phone Consent to Import Medication History I consent to obtaining a history of my medications purchased at pharmacies. Yes No

Primary Care Physician Referring Physician Cardiologist Current Medication Name Dose How taken?

Allergies Patient has no known allergies Patient has no known drug allergies Penicillins Adhesive Tape Antibiotics Eggs Soy Latex gloves Sulfa (Sulfonamide Antibiotics) Contrast Iodine Anesthesia Past or Present Medical Conditions Cancer Esophagus Ovaries Skin Stomach Lungs Colon Rectum Prostate Uterus Leukemia Pancreas Breast Bladder Mouth/Throat Diagnosed GI Conditions Non-Gastrointestinal Conditions Celiac Disease/Sprue Pancreatitis Diverticulosis Hiatal Hernia Anal Fissure Colon Polyps Hemorrhoids Gastric Ulcer GERD Diverticulitis Hepatitis A Hepatitis B Hepatitis C Hepatic Failure Crohn's Disease Alcohol Abuse Irritable Bowel Syndrome Esophageal Stricture Disorder of Gallbladder Cirrhosis/Liver Failure Congestive Heart Failure Intestinal Obstruction Chronic Constipation Gastrointestinal Bleeding Yellow or Jaundiced Color Ulcerative Colitis Clostridium Difficile Infection Barrett's Esophagus Exposure to HIV Asthma Lupus Seizure Disorder Stroke Multiple Sclerosis Helicobacter Pylori/H. Pylori Antibiotic Treatment in Past 3 Months Heart Attack Heart Disease Blood Clots Anemia Thyroid Disease HIV Positive Arthritis Hypertension Fibromyalgia Kidney Disease Unspecified C.O.P.D. Abnormal Heartbeat atherosclerosis Type 1 Diabetes Type 2 Diabetes (hardening of Mellitus Mellitus arteries) Cardiac Arrhythmia High Cholesterol

Diagnostic Studies/Tests Colonoscopy Flexible EGD ERCP EUS Sigmoidoscopy CT MRI MRCP Abdomen/Pelvis Abdominal Ultrasound Abdomen/Pelvis Previous Procedures Appendectomy Colectomy Gallbladder Removal Hiatal Hernia Repair Shoulder Lysis of Adhesions Cosmetic Abdominal aortic aneurysm (AAA) repair Coronary Artery Bypass Graft (CABG) Hysterectomy - Abdominal Defibrillator Placement Transplant - Renal Transplant - Liver Heart Valve Replacement Back Pacemaker Insertion Cesarean Section Craniotomy/Brain TURP Knee Breast Cataract Hip Replacement Hernia Repair - Umbilical Tonsillectomy Cardiac Cath - with stent placement Social History Occupation: Number of Children: Marital Status Single Civil Union Married Divorced Separated Widowed Other Alcohol Daily Weekly Socially Previous Caffeine In the Past 1 cup daily 2-3 cups daily More than 5 Occasional Drug Use Marijuana IV Cocaine Previous Drug Use 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

Family Medical History No knowledge of family history No family history of Celiac sprue Colon cancer Colon polyps Liver disease Ulcerative Colitis / IBD Crohn's disease Stomach cancer Age of Onset Diagnoses Colorectal Cancer Colon Polyps Irritable Bowel Syndrome Liver Disease Ulcerative Colitis Crohn's Disease Celiac Disease Alcohol Abuse Hemochromatosis Autoimmune Hepatitis Liver Failure Ulcer Disease Gallstone Hepatitis B Hepatitis C Stomach Cancer Breast Cancer Uterine Cancer Ovarian Cancer Lung Cancer Skin Cancer Leukemia Pancreatic Cancer Immunizations Flu vaccine PCV7 (Pneumonia)

Review Of Systems Cardiovascular Endocrine Integumentary chest pain excessive thirst hives fainting heat intolerance itching swelling of extremeties jaundice Eyes rashes Respiratory loss of vision Musculoskeletal cough dyspnea wheezing Gastrointestinal back pain joint pain excessive phlegm abdominal pain muscle weakness coughing up blood abdominal swelling stiffness change in bowel habits Constitutional constipation diarrhea Neurological fatigue gas/flatulence dizziness fever heartburn fainting loss of appetite nausea frequent headaches sudden weight loss rectal bleeding migraine night sweats stomach cramps numbness or tingling vomiting seizures ENMT food intolerance vomiting blood memory loss Dementia ear pain black stool nasal obstruction nose bleeds pain with bowel movement incontinence of stool Psychiatric sore throat blood in stool anxiety hearing loss difficulty swallowing depression Sleep Apnea hallucinations Hoarseness Genitourinary nervousness panic attacks dark urine paranoia painful urination frequent urination blood in urine Reviewed with Patient Parent Guardian Not Present Signature Signature Date

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