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Page 1 of 5 Patient Interview Form Patient Information First Name: MRN: Last Name: Date Of Birth: Contact Preference Email Telephone call- Work Telephone call - Home Email Please check one as your preferred email for communications Personal: Work: Sex Male Female Other Race Select one or more White Unknown Black or African American Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Ethnicity Hispanic or Latino t Hispanic or Latino Preferred Language English Spanish; Castilian Pharmacy Name Address Phone

Page 2 of 5 Allergies Patient has no known allergies Patient has no known drug allergies Latex Iodine Containing Drugs Iv Dye, Iodine Containing Penicillins Current Medications Name Dose How taken? Diagnostic Studies/Tests Colonoscopy EGD Stress Test Sleep Study Past or Present Medical Conditions Acid Reflux Irritable Bowel Syndrome Celiac Disease Peptic ulcer disease Hyperthyroidism Anemia Diverticulitis Coronary Artery Disease Ulcerative Colitis Enlarged Prostate (BPH) Barrett's Esophagus Diverticulosis Bleediing Ulcer Diabetes Mellitus, Insulin Dependent Hypothyroidism Colon polyp history Crohn's Disease Helicobacter pylori Diabetes Mellitus, n- Insulin Dependent Hiatal hernia Colitis Hemorrhoids Hypertension Previous Procedures Coronary Artery Bypass Graft (CABG) Gastric Lap Band (banded gastroplasty) Heart Valve Replacement Cardiac Cath - with stent placement Gastric Bypass - type unspecified Defibrillator Cardiac Cath - without stent placement Hiatal Hernia Repair Cholecystectomy -Laparoscopic Pacemaker Insertion Colostomy Hysterectomy - Abdominal

Page 3 of 5 Family Medical History knowledge of family history Health Status Deceased/At Age Diagnoses Colon Cancer Colon Polyps Crohn's Disease Ulcerative Colitis Cancer of Esophagus, Stomach, or Pancreas Liver Disease Celiac disease Social History Occupation: Number of Children: Alcohol Type Quantity Number Frequency Marital Status Single Married Divorced Separated Widowed Civil Union Unknown Other 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 4 of 5 Review Of Systems Allergic/Immunologic HIV exposure persistent infections Cardiovascular chest pain dyspnea with exercise irregular heart beat palpitations peripheral edema syncope Constitutional fatigue fever loss of appetite malaise sweats weight gain weight loss ENMT difficulty swallowing dizziness nose bleeds sore throat hearing loss Endocrine excessive thirst hair loss heat intolerance Eyes double vision loss of vision photophobia Gastrointestinal abdominal pain/bloating abdominal swelling change in bowel habits constipation diarrhea gas heartburn jaundice nausea rectal bleeding stomach cramps vomiting difficulty swallowing Genitourinary decrease in urine flow frequent urinary infections frequent urination hematuria nocturia blood in urine Hematologic/Lymphatic bleeding gums or palpable lymph nodes easy bruising prolonged bleeding Integumentary allergies dryness hives itching jaundice lesions rashes Musculoskeletal arthritis back pain gout joint deformity joint pain muscle weakness stiffness Neurological dizziness fainting frequent headaches migraine numbness or tingling seizures tremors vertigo memory loss Psychiatric anxiety depression difficulty sleeping hallucinations nervousness panic attacks paranoia Respiratory asthma cough dyspnea excessive sputum coughing up blood shortness of breath with exercise wheezing

Page 5 of 5 Consent to Import Medication History I consent to obtaining a history of my medications purchased at pharmacies. Consent to Share Data I consent to having my medical and demographic information shared with other health care entities. Reminder Preference I would like to receive preventive care and follow up care reminders. Reviewed with Patient Parent Guardian t Present

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