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Transcription:

Page 1 of 5 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 Asian Prohibited by state law American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Ethnicity Hispanic or Latino Not Hispanic or Latino Prohibited by state law Sex Male Female Other Preferred Language English Spanish; Castilian Contact Preference Letter Portal Message Reminder Preference I would like to receive preventive care and follow up care reminders. Yes No Allergies Patient has no known allergies Patient has no known drug allergies Aspirin Demerol Iodine Morphine Penicillins Sulfa Valium Versed Other

Page 2 of 5 Current Medications Name Dose How taken? Consent to Import Medication History I consent to obtaining a history of my medications purchased at pharmacies. Yes No Pharmacy Name Address Phone Social History Occupation: Number of Children: Marital Status Single Married Divorced Separated Widowed Alcohol Type Quantity Number Frequency I quit using alcohol Exercise Type Quantity Number Frequency 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

Page 3 of 5 Current Symptoms Allergic/Immunologic flu HIV exposure persistent infections pneumonia Strong Allergic Reaction Cardiovascular ankle swelling chest pain murmur palpitations shortness of breath (lying down) shortness of breath (with exercise) Constitutional fatigue fever loss of appetite weight gain weight loss malaise night sweats Genitourinary blood in urine urinary frequency frequent urinary infections kidney disease/failure kidney stones sexual difficulty heavy periods sexually transmitted diseases Painful urination Hematologic/Lymphatic easy bruising prolonged bleeding swollen glands Integumentary dryness hives itching lesions rashes jaundice Psychiatric anxiety/panic depression difficulty sleeping inability to concentrate loss of interest in enjoyable activites suicidal thoughts Respiratory COPD asthma excessive sputum Endocrine cold intolerance excessive thirst hair/nail changes ENMT hearing loss nose bleeds sore throat difficulty swallowing hoarseness Eyes night sensitivity pain visual decline Musculoskeletal back pain joint pain muscle pain arthritis joint deformity muscle weakness Neurological dizziness frequent headaches numbness or tingling fainting migraine seizures tremors Gastrointestinal abdominal pain belching black stools bloating change in bowel habits constipation dairy intolerance diarrhea difficulty swallowing flatulence heartburn/indgestion hemorrhoids nausea pain with bowel movement rectal bleeding rectal urgency/incontinence vomiting gas jaundice stomach cramps

Page 4 of 5 Immunizations Influenza, seasonal, injectable Pneumonia Hepatitis A Hepatitis B TB/PPD Past or Present Medical Conditions Anemia Arthritis Rheumatoid Arthritis Back Pain (chronic) Cancer (type) Diabetes Mellitus Atrial Fibrilation Asthma Cirrhosis Colon cancer Colon polyps Diverticulitis Diverticulosis Peptic Ulcer Disease Fatty Liver Gallstones Glaucoma Gout Heart Attack Hepatitis (type) High Blood Pressure HIV/AIDS Irregular Heart Beat Kidney Disease Osteoporosis Pancreatitis Paralysis Parkinsons Pneumonia Reflux Rheumatic Fever Skin Cancer Stroke TB (Tuberculosis) Vascular Disease Other Seizures TB Skin Test Positive IBS STD (STI) Thyroid disorder Diagnostic Studies/Tests Endoscopy Colonoscopy Sigmoidoscopy Pacemaker Previous Procedures Appendectomy Breast C-Section Cardiac Surgery Colon Resection ERCP Hysterectomy Gallbladder Removed Joint Replacement Hernia Repair Hemorrhoidectomy Hiatal Hernia Surgery Kidney Liver Biopsy Obesity Surgery Ovary Surgery Prostate Stomach Thyroid Tonsillectomy Tubal Ligation Other

Page 5 of 5 Family Medical History No knowledge of family history No family history of Colon cancer Colon Polyps Health Status Healthy Deceased/At Age Diagnoses Alcoholism Cancer Other: Colon Cancer Colon Polyps Diabetes Heart Trouble High Blood Pressure Liver Disease Lung Disease Pancreatic Cancer Stomach Cancer Other: Reviewed with Patient Parent Guardian Not Present Signature Signature Date

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