Page 1 of 7 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Age: 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 to specify Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Ethnicity Hispanic or Latino Not Hispanic or Latino Patient declines to specify Sex Male Female Other Preferred Language English Patient declines to specify Allergies Patient has no known allergies Patient has no known drug allergies Codeine Penicillins Iodine Latex Sulfa (Sulfonamide Antibiotics) Current Medications Name Dose How taken?
Page 2 of 7 Immunizations PPD Hep A Hep B Pneumovax Diagnostic Studies/Tests Colonoscopy Endoscopy (EGD) Abdominal CT Abdominal MRI Pelvic MRI Pelvic CT Abdominal U/S Pelvic Ultrasound Barium enema x-ray Barium swallow x-ray Cardiac catheterization Echocardiagram DEXA Past or Present Medical Conditions GI Colon polyps Acid reflux Duodenal ulcer Stomach ulcer Barrets esophagus Gallstones Ulcerative colitis Crohn's disease Hepatitis C Hepatitis B Irritable bowel syndrome Rheumatology/ Hematology Osteoarthritis Rheumatoid arthritis Fibromyalgia Anemia/iron deficiency Osteoporosis Bleeding disorder Heart/Lung Coronary artery disease Heart attack Congestive heart hailure Valvular heart disease Atrial fibrillation Pacemaker Defibrillator High blood pressure High cholesterol Stroke Asthma C.O.P.D. Sleep apnea Tuberculosis (TB) Valley Fever Endocrine/ Metabolic/Misc Diabetes Hypothyroidism Hyperthyroidism Kidney Disease
Page 3 of 7 Kidney stones Seizures Glaucoma Headaches Bipolar disorder Anxiety disorder Cancer Colon cancer Prostate Cancer Breast cancer Skin Cancer Lung cancer Previous Procedures Appendectomy Bowel Resection Anti-reflux surgery Hernia Repair Gastric Bypass Lap band Splenectomy Tonsillectomy Thyroidectomy Lumpectomy breast Heart valve replacement Cardiac stent Coronary artery bypass surgery Lung surgery Hysterectomy Ovaries removed Ovary surgery TURP Prostatectomy Vasectomy Back Surgery Vascular Surgery Tubal Ligation Hip Replacement (left) Hip Replacement (right) Knee Replacement (left) Knee replacement (right) Hemorrhoid surgery Gallbladder removal Colon resection Mastectomy Social History Occupation: Number of Children: Marital Status Single Married Divorced Separated Widowed Civil Union Unknown Other Alcohol Type Quantity Number Frequency Caffeine Intake: Intake: 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
Page 4 of 7 Type Started Quit Quantity Frequency Chewing Tobacco Smokeless Drug Use Type Quantity Number Frequency Exercise Type Quantity Number Frequency Family Medical History No knowledge of family history No family history of Colon cancer Polyps Diagnoses Colon cancer Colon polyps Liver cancer Esophagus Cancer Stomach Cancer Pancreas Cancer Ovarian Cancer Uterine Cancer Breast Cancer Kidney Cancer Prostate Cancer Crohn's Disease Ulcerative Colitis Liver Disease Pancreatitis Irritable Bowel Syndrome Heart Disease Eating Disorders Alcoholism Bleeding Disorders Colon Cancer Primary malignant neoplasm
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Page 6 of 7 Review Of Systems Constitutional loss of appetite excessive appetite fatigue difficulty sleeping lack of exercise excessive sweating weight gain weight loss fever ENMT blurred vision double vision eye pain - itchy watery eyes cataracts loss of hearing ear pain ringing in ears dental problems sore tongue taste changes swelling of gums sore throat Respiratory chronic cough productive cough coughs up blood chronic bronchitis sleep apnea shortness of breath with exercise Cardiovascular palpitations angina dizziness shortness of breath with activity elevated on 2 or more pillows to breathe at night swelling of feet/ankles heart murmur chest pain Musculoskeletal joint pain muscle aches back pain joint swelling joint pain from arthritis Genitourinary nocturia hematuria urgency difficulty starting urine burning on urination urinary incontinence weak urine stream prostate problems lumps or masses on testicles discharge from penis painful testicles menstral problems breakthrough bleeding breasts implants breast lump excessive vaginal bleeding postmenopausal hot flashes blood with intercourse premenstrual tension Integumentary chronic skin condition recent rash excessive itching acne Neurological dizziness lightheadedness vertigo numbness or tingling tremors seizures traumatic brain injury Hematologic/Lymphatic bleeds easily bruises easily swollen lymph nods in neck, armpits, groin Endocrine excessive thirst hair loss heat or cold intolerance Allergic/Immunologic HIV exposure immunodeficiency disorder urticaria/hives Gastrointestinal heartburn difficulty swallowing bloating belching nausea vomiting vomiting blood abdominal pain constipation diarrhea stool urgency black stools rectal bleeding pain in rectum incontinence of stools change in bowel habits Psychiatric difficulty making decisions lack of concentration depression cries often worries excessively panic attacks memory loss desires psychiatric help anxiety
Page 7 of 7 Pharmacy Name Address Phone Consent to Import Medication History I consent to obtaining a history of my medications purchased at pharmacies. 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