Health History Questionaire

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Transcription:

Patient DOB: Patient Name: Date: Health History Questionaire Who referred your consultation? If no one referred you, how did you hear about us? Who is your primary care physician? Have you ever seen a gastroenterologist? Please list their name(s). Yes, I am under the care of a gastroenterologist. Yes, I have seen one in the past, but not currently. No, I have never seen a gastroenterologist. Please list your preferred pharmacy What is your primary concern for today's visit? Have you recently experienced any of the following? (Please check all that apply) Trouble Swallowing Weight Loss Abdominal Bloating Food Gets Stuck Weight gain Abdominal pain Choking Change in appetite Recent change in bowel habits Heartburn Feeling full early Diarrhea Nausea Sore Throat Constipation Vomiting Voice Hoarseness Black Tar-like stools Regurgitation Congestion Bleeding from rectum Belching Throat Clearing Vomiting Blood Fevers or chills Shortness of breath Heat or cold intolerance Fatigue Difficulty breathing Trouble with urination Headaches Cough Frequency of urination Dizziness Chest Pain Joint pain or swelling Blurry Vision Palpitations Recent mood changes Double vision Yellowing of eyes or skin Memory changes Hearing changes Skin rashes or lumps Frequently anxious

Have you ever been treated for or had issues with any of the following? (Please check all that apply) Cancer : Ulcers Back/Spinal problems Hay fever Chronic Diarrhea Kidney Stones Food allergies Colon Polyps Other Kidney Problems Heart Attack Diverticulosis/Diverticulitis Goiter or thyoird trouble Irregular Heartbeat Irritable or spastic colon Diabetes Valvular heart disease Colitis Anemia (low blood count) Congestive Heart Failure Gallstones Blood clot in lungs or legs High blood pressure Pancreatitis Other blood disorders High cholesterol Hepatitis Poor Circulation Pneumonia Other Liver Disease Arthritis Asthma Genital Disorders Stroke Empysema or Bronchitis Prostate Trouble Seizures Other lung disease Endometriosis Depression or Anxiety Have you every had the following operations? (Please check all that apply) Fundoplication/ Anti-reflux Surge Removal of appendix Eye Surgery Myotomy for Achalasia Hemorrhoid Surgery Tonsillectomy Removal of partial/all of stomach Removal of Spleen Prostate surgery Gastric bypass Removal of part/all of colon Hysterectomy Gastric sleeve Heart Bypass Ovearies Removed Lap Band placement Angioplasty Tubes tied Hiatal hernia repair Replacement of Heart Valve Removal of Kidney Any other surgery on the Artificial blood vessel graft Placement of artificial joint esophagus or stomach? Inguinal hernia repair Removal of gallbladder Removal of gallbladder Have you every had the following procedures (Please check all that apply) Upper endoscopy ( a lighted camera that goes into your mouth usually while you are sedated) Barium Swallow or Esophagram (You drink barium and are placed in different positions for X ray pictures) Esophageal motility study (a catheter that goes through your nose and you drink atleast 10 sips of salty water) Esophageal ph catheter based monitoring (a catheter that goes in your nose and monitors acid for 24 hours) Esophageal ph wireless monitoring (a caspsule attached to your esophageal lining to monitor acid) Colonoscopy Please list any other medical conditions or operations:

Patient Name: Patient DOB: Please list any food or drug allergies and the reaction: Please list all medications you currently take or provide your current medication list on another sheet: Name, Dose, and Frequency of Medication: Please circle yes or no for each of the following questions. Are you on medications for diabetes? Yes No Are you on steroids? Yes No Are you on any blood thinners? Yes No Are you currently taking an acid suppression tablet regularly? Yes No Have you ever been told you have a difficult airway or intubation? Yes No Have you ever had a problem with anesthesia. Please explain. Yes No Do you have sleep apnea or do you currently use a CPAP machine? Yes No Family History Please list any significant medical condition Father: Alive Deceased Medical Problems/Cause of Death: Mother: Alive Deceased Medical Problems/Cause of Death: Number of Siblings: Sisters Brothers Number of Children: Sons Daughters Is there any family history of the following? Please list the family member. Esophageal Cancer Heart Disease Stomach Cancer Colon Cancer Diabetes Eosinophillic Esophagitis Celiac Disease Breast Ovary Endometrial or Uterine Cancer Liver Disease Pancreatic Disease Other cancers Ulcerative Colitis Crohn's Disease

Social History Please list your current marital status: Who lives at home with you? What is the highest level of education you have achieved? Some School Some College Masters or Doctorate Degree Highschool College Degree In regards to school or work, check all that apply: Working full time Stay at home parent / caregiver In School Working part time Retired What is your occupation / trade? Tobacco Have you used tobacco products? Types of Tobacco used (check all that apply): Never smoked Cigarette Chewing products Current user Cigars Vapor Former user If you are a current tobacco user, how often do you use tobacco? If you are a current tobacco user, how often do you use tobacco in a day? If you are a former tobacco user, how long has it been since your last use? How many years have you used tobacco? Alcohol Have you had a drink with alcohol in the past year? No Yes If yes, How often have you had a drink containing alcohol in the past year? Never Monthly or Less 2-4 Times a month 2-3 Times a week 4 or More Times a Week If yes, how many drinks did you have on a typical day when you were drinking? If yes, please check all types of alcohol that was consumed: Beer Wine Hard Liquor Drugs Do you smoke Marijuana? No Yes If so, how frequently? Do you use any other illicit drugs? Please list: Have you used any IV drugs (requring a needle)? Please list: Do you have any tattoos? No Yes Do you have any piercings? No Yes Where? Signature: Date:

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