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Transcription:

Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: tes: Contact Preference Email Telephone call/leave message Patient declines to specify Email Please check one as your preferred email for communications Personal: Work: Allergies Patient has no known allergies Patient has no known drug allergies Aspirin Codeine IV Contrast or Iodine Penicillin Propofol Eggs Latex Sulfa (Sulfonamide Antibiotics) Past or Present Medical Conditions and Liver Barrett's Esophagus Cirrhosis of liver Colon Cancer Colon Polyps Crohn's Disease Diverticulitis Diverticulosis Esophageal Varices Elevated Liver Enzymes Hepatic encephalopathy Irritable Bowel Syndrome Stomach or Duodenal Ulcer Fatty liver Gastric Varices GERD (reflux / heartburn) Hepatitis A Hepatitis B Hepatitis C Liver transplantation Pancreatitis, acute Ulcerative Colitis Pancreatitis chronic Abdominal aortic aneurysm Coronary Artery Disease without heart attack Hyper cholesterolemia Atrial Fibrillation Deep vein thrombosis Cardiac valvular disease Heart Attack Congestive Heart Failure Heart Murmur Hypertension Stroke (CVA) Transient ischemic attack Page 1 of 5

Conditions Alcoholism Anxiety Alzheimer Anemia, nonspecific Asthma B12 deficiency Anemia Breast cancer Chronic pain syndrome Chronic COPD Degenerative Diabetes anticoagulation joint disease Mellitus Dialysis Depression Drug abuse / Fibromyalgia dependency Glaucoma Gout HIV/AIDS Home Oxygen Hyperthyroidism Hypothyroidism Iron Deficiency Anemia Kidney Stones Kidney Disease Parkinson's disease Rheumatic Kidney Lymphoma Osteoporosis Transplant PPD positive Pneumonia Prostate Cancer Rheumatoid Fever arthritis Tuberculosis Seizure disorder Skin Cancer Diagnostic Studies/Tests Colonoscopy Flexible sigmoidoscopy EGD (upper endoscopy) Liver biopsy ERCP Capsule Endoscopy Previous Procedures Surgery/Procedures Appendectomy Colon Resection (part of colon removed) Hiatal hernia surgery/antireflux surgery Billroth I Gastric banding Lysis of adhesions Billroth II Gastric bypass Partial gastrectomy Cholecystectomy (gall bladder removed) Hemorrhoid surgery Small bowel resection Surgery/Procedure Abdominal aortic aneurysm Carotid endarterectomy Mitral valve Breast Cancer Surgery Nephrectomy Aortic Valve Replacement Cardiac stent Peripheral vascular surgery C-Section Prostatectomy Cardiac pacemaker Cardiac defibrillator Groin hernia Thyroid Coronary artery bypass graft (CABG) Cardiac valve Hysterectomy Tonsillectomy Total hip Total knee Tubal Ligation Page 2 of 5

Family Medical History knowledge of family history family history of Colon cancer Polyps Health Status Healthy Deceased/At Age Diagnoses Colon polyps Colon cancer Alcoholism Breast Cancer Bleeding tendency Cancer ()-specify type if known Diabetes Heart attack Liver disease Social History Occupation: Number of Children: Marital Status Single Married Divorced Separated Widowed Alcohol Type Quantity Number Frequency Example - Wine Glass 2 Times / week Beer Wine 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 I have never used drugs I have used drugs in the past I currently use drugs I have been treated for substance abuse Page 3 of 5

Review Of Systems Allergic/Immunologic Allergies (environmental) Recurrent hives chest pain shortness of breath with exertion shortness of breath-lying flat palpitations Ankle swelling Constitutional fatigue weight gain weight loss ENMT nose bleeds sore throat hearing loss Endocrine excessive thirst hair loss cold intolerance Eyes Visual decline abdominal pain black tarry stools bloating change in bowel habits constipation diarrhea difficulty swallowing heartburn milk/dairy intolerance mucous in stool nausea pain with bowel movement rectal bleeding rectal urgency soiling stool vomiting Genitourinary frequent urinary infections change in urinary frequency kidney disease/failure Hematologic/Lymphatic easy bruising prolonged bleeding Integumentary dryness hives itching rashes Musculoskeletal joint pain joint swelling muscle pain Neurological dizziness frequent headaches numb extremities Psychiatric anxiety/panic depression suicidal thoughts Respiratory cough excessive sputum shortness of breath wheezing cough up blood Page 4 of 5

Pharmacy Name Address Phone Current Medications Name Dose How taken? Consent to Import Medication History I consent to obtaining a history of my medications purchased at pharmacies. Reminder Preference I would like to receive preventive care and follow up care reminders. Consent to Share Data I consent to having my medical and demographic information shared with health care entities. Signature Signature Date Page 5 of 5

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