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Transcription:

Page 1 of 5 Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: Allergies Patient has no known allergies Patient has no known drug allergies Latex IV dye Current Medications Name Dose How taken? Pharmacy Name Address Phone Immunizations Hepatitis A Zoster (Live) Hepatitis B HPV Pneumococcal conjugate Flu vaccine A/B injection Meningococcal conjugate

Page 2 of 5 Social History Occupation: Number of Children: Alcohol 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 Type Quantity Frequency Drug Use Type Quantity Frequency Marijuana Other Diagnostic Studies/Tests TB Quantiferron or skin test TPMT Geno/Phenotype MRI Cocci titers Liver Biopsy Recent Hospitalization Hep A/ B/ C antibodies DEXA/Bone density Labs within the last 3-months JCV Antibody Abdominal Ultrasound Celiac serology CT Previous Procedures EGD Bravo ph monitor Small bowel surgery Carotid Stent Thyroidectomy Colonoscopy Nissen Fundoplication Hemorrhoid Surgery CATH - Cardiac Hysterectomy Capsule endoscopy Cholecystectomy Hemorrhoid Banding Coronary artery bypass surgery Joint replacement Endoscopic Ultrasound Appendectomy Colon Resection Heart Valve (aortic or mitral) Abdominal hernia repair manometry Gastric By-Pass Cardiac Ablation Pacemaker or defibrilator

Page 3 of 5 Past or Present Medical Conditions GI bleed Crohn's Disease Barrett's Esophagus Liver Problems Hepatitis other Gastric Cancer Irritable Bowel Syndrome Colon polyps Peptic ulcer disease Elevated liver enzymes Fatty Liver Diverticulosis Colon cancer Stricture Cirrhosis Pancreatitis Diverticulitis Helicobacter pylori infection Celiac Disease Hepatitis C Pancreatic cancer Ulcerative Colitis GERD Gallstones Hepatitis B Cancer Cardiac Heart Valve replacement Angina Endocarditis MI/heart attack Atrial Fibrillation Hypertension Arrhythmia Cardiac Stents Pulmonary Asthma Valley Fever COPD Deep vein thrombosis Pulmonary embolus Sleep apnea Pneumonia Lung Cancer Genito/urinary Urinary Tract Infections Kidney Disease Ovarian Cancer Urinary Incontinence kidney stones Uterine Cancer Kidney transplant Kidney Cancer Prostate Cancer Endocrine Hypothyroidism Hyperthyroidism Diabetes Hyperlipidemia Osteoporosis Adrenal insufficiency Hema/Immuno: Blood transfusion Breast cancer Anemia Lymphoma Iron Deficiency Immunodeficiency Neurological Epilepsy or seizures Migraine TIA/Mini-stroke Stroke Neuropathy Psychiatric Depression Bipolar Anxiety Panic disorder

Page 4 of 5 Opthamological Glaucoma Blind Cataracts Dermatological Psoriasis Skin Cancernon melanoma Melanoma Hair loss Ear/Nose/Throat Hearing loss Sinus disease Throat Cancer Rheumatologic Gout Scleroderma Osteoarthritis Systemic Lupus SJogrens Fibromylagia Rheumatoid arthritis Additional social High risk sexual esposures Tatoos Piercings Occupational exposures Family Medical History No knowledge of family history No family history of colon cancer colon polyps Crohn's Disease IBD liver disease pancreatic cancer ulcerative colitis Diagnoses Colon Cancer Colon Polyps Pancreatic cancer Stomach Cancer Breast Cancer Cervical Cancer Crohn's disease Ulcerative Colitis Celiac Disease Liver Cancer Liver cirrhosis/disease Cancer

Page 5 of 5 Review Of Systems Allergic/Immunologic HIV exposure persistent infections strong allergic reactions or urticaria Food allergies Constitutional fatigue fever chills loss of appetite weight gain weight loss post-prandial fullness ENMT dizziness nose bleeds loss of vision double vision hoarseness of voice Post nasal drip Vertigo Endocrine hair loss heat intolerance Cold intolerance Flushing Cardiovascular chest pain shortness of breath with exercise irregular heart beat palpitations ankle swelling fainting Respiratory asthma cough shortness of breath excessive sputum shortness of breath with exercise wheezing Oxygen dependence hemoptysis Gastrointestinal abdominal pain Abdominal distention/bloating heartburn reflux gas Indigestion difficulty swallowing/dysphagia solids stick with swallowing liquids stick with swallowing coughing with swallowing Early Satiety nausea vomiting change in bowel habits diarrhea constipation straining with defecation rectal bleeding wipe bleeding Black Stools Anal pain Anal itching Anal burning Anal pressure Anal leaking/soiling fecal incontinence Ascites jaundice Elevated liver enzymes enlarged liver pancreatitis Genitourinary dark urine urinary burning frequent urination hematuria urinary incontinence urinary hesitancy Hematologic/Lymphatic bleeding gums or palpable lymph nodes easy bruising prolonged bleeding anemia Integumentary dryness hives itching jaundice rashes Open wounds or sores Seasonal allergies Musculoskeletal arthritis joint pain back pain gout muscle weakness stiffness Neurological dizziness fainting migraine headaches numbness or tingling seizures tremors vertigo Psychiatric anxiety panic attacks depression paranoia difficulty sleeping hallucinations Schizophrenia Sleep apnea

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