PATIENT INFORMATION (Please print all information) Date:

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320 Lillington Ave Suite 101 Charlotte, NC 28204-3189 Phone: 704.362.4403 Fax: 704.362.4405 Please fill out the following form completely so that we may obtain the necessary information for our files and background information on your medical problem. In this way, more time will be available for you to talk to the doctor at the time of your visit. All information is held in strict confidence and will NOT be released to anyone without your written consent. PATIENT INFORMATION (Please print all information) Date: Referring Physician: Phone Number: Primary Care Physician: Phone Number: Name: Date of Birth: Age: Mailing Address: Sex: Race: Home Phone: Cell Phone: SSN: Occupation: Employer: Work Phone: Emergency Contact Person: Relationship: Phone: E-mail Address: ALLERGIES: Please list any allergies that you have and your reaction: FAMILY HISTORY ONLY: Please circle yes or no for each item for family members only. If yes, please indicate their relationship to you on the line provided. Relationship Relationship Anemia Gallstones Breast Cancer Heart Disease Celiac Disease Hemochromatosis Cervical Cancer Hepatitis C Cirrhosis of Liver Irritable Bowel Syndrome Colon Cancer Ovarian Cancer Colon Polyps Pancreatic Cancer Crohn s Disease Pancreatitis Diabetes Peptic Ulcer Disease Esophageal Cancer Ulcerative Colitis Gastric Cancer Uterine Cancer Reaction to anesthesia

YOUR PAST MEDICAL HISTORY: Please circle yes or no for each item for yourself only. CANCER HEART (continuation) Breast Cancer High Blood Pressure Cervical Cancer Mitral Valve Prolapse Colon Cancer Palpitations Esophageal Cancer Rheumatic Fever Leukemia Pacemaker Liver Cancer BLOOD Lymphoma Anemia Ovarian Cancer Bleeding or clotting abnormalities Pancreatic Cancer Hemophilia Prostate Cancer VonWillebrands Stomach Cancer HIV / AIDS Uterine Cancer INTEGUMENTARY Eczema RENAL Melanoma Dialysis Psoriasis Kidney Failure NEUROLOGICAL MUSCULOESKELETAL Alzheimer/Dementia Fibromyalgia Brain Aneurysm Gout Migraines Lupus Myasthenia Gravis OsteoArthritis Seizures Osteoporosis Stroke Reynaud s Rheumatoid Arthritis RESPIRATORY Scleroderma Asthma Sjogrens COPD (Emphysema) Sleep Apnea PSYCHOLOGICAL Tuberculosis (TB) Anxiety Bipolar GASTROINTESTINAL Depression Angiodysplasia of GI Tract Obsessive Compulsive Disorder Barrett s Esophagus Esquisofrenia Celiac Disease Colon Plyps LIVER Crohn s Disease Cirrhosis Diverticulitis Fatty Liver Diverticulosis Hemochromatosis Hemorrhoids Hepatitis A IBS (Irritable Bowel Syndrome) Hepatitis B Pancreatitis Hepatitis C Peptic Ulcer Disease Jaundice yes Reflux Ulcerative Colitis HEART Congestive Heart Failure ENDOCRINOLOGY Endocarditis Diabetes, Type I (insulin needed) Heart Attack (Myocardial Infarction) Diabetes, Type II (pills needed) Heart Valve Disease Thyroid Disease

SURGERIES: Please circle yes or no for each item for yourself only. If yes, please indicate the date on the line provided. Month / Year Month / Yr GASTROINTESTINAL GU Appendectomy Bladder Surgery Capsule Endoscopy Cystectomy with Ileal Conduit Cholecystectomy (Gallbladder Removal) Kidney Removal (nephrectomy) Colon Surgery Prostate Removal (Prostatectomy) Colonoscopy Radiation for Prostate Cancer ERCP TURP EUS Gastric Bypass CARDIAC Gastric Surgery Abdominal Aneurysm Hiatal Hernia Repair Angioplasty Inguinal Hernia CABG (Coronary Bypass) Manometry Cardiac Catherization Pancreatic Surgery PEG Tube Placement FemPop bypass (Leg Arteries) Esplenectomy (removal of spleen) Heart Stent placed Heart Valve Replacement Surgery for Intestinal Adhesions Pacemaker Umbilical Hernia Defibrillator Upper Endoscopy (EGD) OTHER GYNECOLOGICAL C-Section Hysterectomy (Abdominal) Hysterectomy (Vaginal) Mastectomy (right) Mastectomy (left) Have you ever had a complication to Anesthesia? Mastectomia (both) YES NO Ovary Removal (right) Ovary Removal (left) Ovary Removal (both) SOCIAL HISTORY: Marital Status: Married Single Widow Divorced Use of Tobacco: Use of Alcohol: Use of Drugs: history of tobacco use History of alcohol use History of drug use History of tobacco use History of alcohol use History of drug use Packs per day Glasses daily IV drug abuse Years of use Glasses weekly Marijuana Year quit Glasses occasional Crack/Cocaine History of alcoholism Year quit

REVIEW OF SYSTEMS: Please circle yes for each symptom or disease diagnosed for you during the last 2 months. Circle no for all others. GENERAL RESPIRATORY Loss of Appetite/Anorexia Cough Fatigue Shortness of breath Fever Wheezing Night Sweats CARDIOVASCULAR Weight Gain in the last 3 months Chest pain Amount Weight loss in the last 3 months Edema/ swelling Amount Are you under any stress? Difficulty breathing while laying down Eye pain Palpitations SKIN Shortness of breath Skin Rash NEUROLOGICAL Incontinence Stool ENT Numbness Hoarseness Weakness Oral Ulcers Voice changes GASTROINTESTINAL Headache Frequent constipation Vision Problems Pain with bowel movement Loss of visión Pale, greasy, oily, or rancid stools Double vision Mucus in or on your stool Blurred vision Frequent diarrhea Black or sticky stools HEMATOLOGY Blood in or on your stools Enlarged Lymph des Vomit frequently Prolonged Bleeding Vomit blood or coffee grounds Bloating, belching, or excessive gas GENITOURINARY Difficult or painful swallowing Blood in urine Frequent heartburn or indigestion Painful urination Frequent stomach pain Recent changes in your bowel movement Jaundice (yellow eyes)

PATIENT MEDICATION LIST Please print! Medication list should include all over-the-counter and taken-as-needed medications. Local Pharmacy: Location: Mail Order Pharmacy: Medication Name Strength (mg) Number of Times Taken Daily Reason

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