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Page 1 of 5 Orange Coast Memorial Office: 18111 Brookhurst Ave. Suite 5200, Fountain Valley, CA 92708 * Tel: (714) 962-7705 * Fax: (714) 861-4552 www.unitedgi.com Patient Interview Form Patient Information First Name: Last Name: Date Of Birth: Email Personal: Contact Preference Home Phone Cell phone Email Sex Male Female Other 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 Preferred Language English Korean Spanish; Castilian Allergies Patient has no known allergies Patient has no known drug allergies Penicillins Aspirin Vicodin Codeine Sulfate Propofol Analogues Sulfa (Sulfonamide Antibiotics) Versed Iodine And Iodide Containing Products

Page 2 of 5 Current Medications Name Dose How taken? Past or Present Medical Conditions Acid reflux Barrett's Esophagus Celiac disease Colon cancer Colon polyps Crohn's Disease Diverticulosis Fissure (anal) Hemorrhoids Hepatitis Irritable bowel syndrome Liver disease Stomach ulcer Ulcerative colitis Anemia Anxiety disorder Arthritis Asthma Cardiac Stents Cancer Pacemaker/ defibrillator High cholesterol Heart Disease Depression Diabetes Fibromyalgia High blood pressure Hyperthyroidism Hypothyroidism Taking blood thinners Do you know of any Children who would benefit from seeing a Pediatric Gastroenterologist? Kidney disease Sleep apnea Stroke Hernia Previous Procedures Appendectomy Cardiac stent placement Colon, Bowel Resection Gastric Bypass Cholecystectomy Hysterectomy Heart valve replacement Joint replacement Lap Band Diagnostic Studies/Tests Colonoscopy Upper endoscopy (EGD) Other Recent Imaging/Labs Social History Occupation: Number of Children: Marital Status Single Married Divorced Separated Widowed Alcohol

Page 3 of 5 Less than 7 drinks weekly, and no more than 3 drinks on More than 7 drinks weekly, and/or more than 3 drinks on Less than 14 drinks weekly and no more than 4 drinks on More than 14 drinks weekly and/or more than 4 drinks on Former alcohol abuse, now sober 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 Past use of drugs Current use of drugs Type: Family Medical History No knowledge of family history No family history of Colon cancer Gastrointestinal cancer Diagnoses Celiac Disease Colon Cancer Breast Cancer Crohn's Disease Colon Polyps Diabetes Esophageal Cancer Ovarian Cancer Pancreatic Cancer Gastric Cancer Small Bowel Cancer Uterine Cancer Ulcerative Colitis Brain Cancer Hypertension/High Blood Pressure Kidney Cancer Fam hx malig gi tract

Page 4 of 5 Review Of Systems Gastrointestinal abdominal pain abdominal distention, bloating nighttime awakening from abdominal pain abnormal bowel movements diarrhea constipation loose stools recent changes in bowel habits bloody diarrhea rectal bleeding black, tarry stools rectal pain fecal incontinence heartburn nausea vomiting belching vomiting blood gas Allergic/Immunologic persistent infections Cardiovascular chest pain irregular heart beat syncope heart murmur Constitutional fatigue fever Chills sweats loss of appetite weight loss Endocrine excessive thirst heat intolerance cold intolerence excessive urination Eyes yellowing of eyes redness of eyes Genitourinary dark urine dysuria frequent urination urinary incontinence urgency heavy menstrual periods Hematologic/Lymphatic easy bruising prolonged bleeding swollen lymph nodes recent anemia Integumentary itching yellowing of skin lesions rashes Musculoskeletal arthritis back pain joint pain stiffness swelling Neurological dizziness seizures confusion Psychiatric anxiety depression nervousness agitation Respiratory cough shortness of breath wheezing ENMT difficulty swallowing dizziness sinus pain Ringing of the ears hoarseness neck swelling 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

Page 5 of 5 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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