Patient Name Date Referring M.D. Occupation Married Divorced Single Widowed

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Transcription:

Patient Name Date Referring M.D. Birth date / / Age Explain your reason for the visit: Occupation Married Divorced Single Widowed Abdominal pain No yes Intensity of the pain/ Mild /moderate/ severe /10 Scale [1/10 ---10] /10 Date of onset: Onset sudden/slow Constant or intermittent Duration /seconds/ min/hours Frequency: Character of pain Aggravated by: Relieved by: Relationship to Food/hunger Relationship to bowel movement Location: Radiation Vomiting No yes undigested food / acid sour / bile / bitter/ Food eaten several hours or days back Vomitingblood No yes Red/coffeegrounds No yes Black tarry stool No yes Heartburn or acid reflux No yes Frequency day/week/month/year: Nocturnal: No yes Difficulty swallowing since No yes Intermittent Progressive Location solids Liquids Pain on swallowing No yes Decrease in appetite No yes Aspiration No yes Pnuemonia No yes Diarrhea Date of onset No yes large/small; during the day; Day & night; Relationship to Food Blood in stool No yes Top of the stool Mixed in stool Excess Mucous in stool No yes Pain on passage of stool No yes Incomplete stool passage No yes Constipation No yes # bowel movements per week Gas or bloating No yes Incontinence accidents No yes Jaundice No yes Dark urine No yes Pale stool No yes Hepatitis No yes Itching all over the body No yes Abdominal distention No yes Easily bruised No yes Confusion No yes Weight gain No yes

Medications: (Prescription, vitamins & over-the-counter) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Do you take any of the following OTC medications? No Yes, if so which ones and how often: ASPIRIN MOTRIN ADVIL ALEVE IBUPROFEN ANACIN EXCEDRIN # Daily # Weekly # Monthly # as needed/ what for? Surgeries: Year: Medication Allergies Type of reaction (such as rash or breathing) 1. 1. 2. 2. 3. 3. 4. 4. 5. 5. Other Illnesses (Diabetes/ High blood pressure/ Heart disease etc) Year Diagnosed 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Family History: circle relation and enter age diagnosed in the space Colon Cancer: Colon Polyps: Colitis: Crohn s: Liver Disease: Pancreas cancer: StomachUlcer: Stomach Cancer: Current Illnesses of Family Members (if deceased -age s and cause): Father: Brothers: Uncles/Aunts: Children: Mother: Sisters: Grandparents: Grandchildren: Patient s Signature Date

Personal: SmokeTobacco: Never Yes # of years Packs Per Day Year quit Chew Tobacco: Never yes # of years Packs Per Day Year quit Alcohol use: Never Socially Rarely Regularly # of years Drinks Per Week Year quit Alcohol Dependent Tattoos: None yes Where/who placed it from When was it placed Body piercing IV Drug use: Never yes When last used Inhalation drug use Never yes When last used High Risk Sexual Behavior: no, only one partner ever yes, multiple partners/unprotected sex (ever) Sexual orientation Blood Transfusion: Never yes Year of transfusion where Transfusion before 1990 yes No Cups of Coffee #Daily # Weekly Cups of Soda #Daily # Weekly Chewing Gum No yes occasionally yes daily/how often Health Food/ Herbal product use: 1. 2. 3. 4. 5. 6. 7. 8. Endoscopy History: Date of last Colonoscopy By Whom/hospital/City/ State Results/Findings Recommendations Previous colonoscopies (Year ) Date of last EGD (stomach scope) By Whom/ hospital/city, State Results/Findings Recommendations Radiological History: Barium Swallow (X-ray) Date Location Results Barium Enema (X-ray) Date Location Results Abdominal Ultrasound Date Location Results CT Scan (abd/pelvis) Date Location Results MRI (abd/pelvis) Date Location Results Patient s Signature Date

Please indicate yes or no as we are not able to assume your response to the following pages. A line or check will let us know that you have read and understood the symptoms listed. REVIEW OF SYSTEMS NO YES, COMMENTS Constitutional > 10 lb. weight loss in past year > 10 lb. weight gain in past year Fever within past month Chills or sweats within past month Chronic fatigue Anorexia/ poor appetite Eyes Blurred or double vision Cataracts or glaucoma Frequent red eye Ears, Nose, Mouth Throat Hearing Loss Ringing in the ears Sore Throat/hoarseness Sinus problems Nose Bleeds Cardiovascular Chest pain or pressure Rapid or irregular heart beat Abnormal swelling in legs or feet High blood pressure Vascular disease Coronary Artery Disease Difficulty breathing Respiratory Shortness of breath Wheezing or Asthma Persistent cough Coughing up sputum or blood Exposed to Tuberculosis Difficulty breathing on exertion Chronic Bronchitis/Emphysema Genitourinary Frequency of urination Difficulty starting urinary stream Leaking urine Burning/pain with urination Blood in urine Urinary tract infections Stones or kidney problems Patient s Signature Date

REVIEW OF SYSTEMS NO YES, COMMENTS Musculoskeletal Pain/stiffness/swelling in joints Morning Stiffness Chronic Backaches Osteoporosis Neurological Frequent headaches Dizziness Problems with balance Numbness or tingling Seizures Blacked-out or lost consciousness slurred speech Skin/Breast Skin rashes/cancer Breast mass/discharge Psychiatric Anxiety Memory loss Depression Suicidal ideation Mental Illness Endocrine/Metabolic Excessive thirst/urination Diabetes Onset Thyroid Disease Onset Menses Heavy / scant Stopped at age Vaginal bleeding High cholesterol/triglycerides Hematologic/Lymphatic Enlarged glands (lymph nodes) Excessive bruising Abnormal bleeding Anemia Patient s Signature Date

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