New Patient Medical History Form

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Transcription:

New Patient Medical History Form Date: Name: Date of Birth: Address: City: ZIP: Home Phone #: Cell Phone #: Emergency Contact: Relationship: Emergency Contact Phone #: Primary Care Physician: Referring Physician (if different): MAIN REASON FOR VISIT: How long have these symptoms: years months weeks days hours Location of symptom: Intensity: mild moderate severe Quality of pain (if applicable): sharp dull aching cramping pressure other: List anything(s) that make your symptom(s) better (e.g. eating, bowel movements, changes in position, medications, or other treatments): List anything(s) that make your symptom(s) worse (e.g. eating, bowel movements, changes in position, medications, or other treatments): Have you had any prior testing for this symptom(s) (e.g. blood tests, X rays, endoscopies): CURRENT MEDICATIONS: (list all prescription and over the counter medications, vitamins, supplements, etc): 1

NAME DOSE (e.g. milligrams) FREQUENCY (e.g. daily, twice daily, as needed) Pharmacy Name: Phone #: ALLERGIES: MEDICATION TYPE OF REACTION PAST MEDICAL HISTORY (check all that apply): None Anemia Blood Clots (Deep Vein Thrombosis) Cancer (type): Depression Diabetes Anxiety Arthritis Asthma Atrial Fibrillation Bipolar Disorder Cirrhosis COPD/Emphysema Colon polyps Coronary Artery Disease Crohn s Disease Diverticulosis Diverticulitis Endometriosis Gastrointestinal Bleeding GERD 2

Hepatitis (A, B, C) Hyperlipidemia (high cholesterol) Hypertension (High Blood Pressure) Heart Disease Heart Attack Heart Failure Irritable Bowel Syndrome (IBS) Stroke Kidney Stones Lupus Kidney Failure/Dialysis Rheumatoid Arthritis Osteoporosis Seizure Disorder Sleep Apnea Thyroid Disorder Ulcers (stomach or intestinal) Ulcerative Colitis Other Medical Conditions: PAST SURGERIES (check all that apply): None Colonoscopy, when: Findings: Upper Endoscopy, when: Findings: Angioplasty Appendix Removal Bowel Surgery Cataract Surgery Cesarian Section (C section) Coronary (Heart) Stent Placement Coronary (Heart) Bypass Surgery Gallbladder Removal Gastric Bypass Surgery Heart Valve Repair or Replacement Hernia Repair Hemorrhoid Surgery Hip Replacement or Repair Hysterectomy (Uterus Removal) Knee Replacement or Repair Oophorectomy (Ovary Removal) Pacemaker or Defibrillator placement Other Surgeries: SOCIAL HISTORY (check all that apply): Do You Smoke? No Quit: (year) Yes: Cig/Packs/Day for #Years Do You Drink Alcohol? No Quit: (year ) Yes: Drinks per Day/Week/Month for # Years Do You Use Recreational Drugs: No Quit: (year) Drugs used previously: IV? Yes Drugs used currently: IV? Tattoos 3

Blood Transfusions? When: Marital Status: Married Separated Single Divorced Widowed Highest Level of Education Completed: Occupation: FAMILY HISTORY (check all that apply): Colon Cancer Colon Polyps Esophagus Cancer Stomach Cancer Intestinal Cancer Pancreas Cancer Liver Cancer Liver Disease Celiac Disease Crohn s Disease Ulcerative Colitis Irritable Bowel Syndrome Breast Cancer Uterus Cancer Ovarian Cancer Kidney Cancer Skin Cancer Heart Disease Diabetes Other: FATHER MOTHER SIBLING OTHER FATHER MOTHER SIBLING OTHER REVIEW OF SYSTEMS (check all that apply): Gastrointestinal Abdominal Pain Nausea Vomiting Vomiting of Blood Vomiting of Bile Difficulty Swallowing Pain With Swallowing Heartburn Belching/Burping Gas/Bloating Abdominal Distension Decreased Appetite Diarrhea Constipation Blood in the Stool Black/Tarry Stools Change in Bowel Habits Pain with Bowel Movements Rectal Pain/Itching Incontinence Constitutional Weight loss: lbs. Weight gain: lbs. Fevers Chills Fatigue Weakness Cardiovascular Chest Pain/Discomfort Palpitations Lightheadedness Dizziness Passing Out Shortness of Breath Leg Swelling Dermatologic/Integumentary Skin Rash Dry Skin Itching Jaundice Change in Skin Color 4

Hair Loss Breast Pain/Lump/Discharge Leg swelling Varicose Veins Lumps Felt in Neck, Armpits, Groin, etc Ear/Nose/Throat Hearing Loss Ringing in Ears Ear Aches Ear Infections Sinus Infections Runny Nose Nose Bleeds Sinus Drainage Sore Throat Hoarse Voice/Change in Voice Seasonal/Environmental Allergies Eyes Vision Loss Blurry Vision Light Sensitivity Dry Eyes Eye Infections Endocrine Excessive Thirst Heat/Cold Intolerance Night Sweats Chills Hot Flashes Genitourinary Sexually Transmitted Diseases Painful/Burning/Difficulty Urinating Frequent Urination Penile Discharge Blood in Urine Urinary Incontinence Kidney Stones Testicular Pain Testicular Lumps Pain with Sexual Intercourse Gynecologic/Reproductive Vaginal Discharge Irregular Menstrual Bleeding Excessive Menstrual Bleeding Infertility (female/male) Hematologic Bleeding Disorder Easy Bleeding/Bruising History of Blood Clots Musculoskeletal Joint Pain Joint Weakness Joint Stiffness Muscle Pain Muscle Weakness Muscle Stiffness Back Pain Neck Pain Neurologic Headaches Dizziness/Vertigo Double Vision Blurry Vision Slurred Speech Tremors Seizures Numbness Paralysis Stroke Head Trauma/Injury Balance Problems Difficulty Walking Pulmonary Shortness of Breath Coughing Wheezing Coughing Up Blood Psychiatric Depression Anxiety Mood Changes Suicidal Thoughts Insomnia Memory Loss Confusion 5

Signature of Patient or Legal Representative Date Reviewing Physician Signature Date www.gispecialtycare.com Bolingbrook Office 396 Remington Blvd Suite 260 Bolingbrook, IL 60440 (630) 312 2590 (Office) (630) 679 1742 (Fax) Plainfield Office 15724 S Route 59 Suite 102 Plainfield, IL 60544 (630) 312 2590 (Office) (630) 679 1742 (Fax) Hinsdale Office 911 N. Elm Street, Suite 327 Hinsdale, IL 60521 (630) 312 2590 (Office) (630) 679 1742 (Fax) 6

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