Page 1 of 6 Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: Notes: Email Please check one as your preferred email for communications Personal: Work: Race Select one or more White Unknown Black or African American Patient declines Asian Prohibited by state law American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Ethnicity Hispanic or Latino Not Hispanic or Latino Patient declines Prohibited by state law Sex Male Female Other Preferred Language Patient declines Contact Preference Telephone call Patient Portal Patient declines Other:
Page 2 of 6 Allergies Patient has no known allergies Patient has no known drug allergies Medication Allergies Sulfa (Sulfonamide Antibiotics) Codeine Sulfate Other: Propofol Penicillins Versed Other Allergies Eggs Latex Other: Current Medications Name Dose How taken? Immunizations Other: Hep A, adult Hep B Flu vaccine zoster Pneumococcal conjugate PCV 13 Diagnostic Studies/Tests Colonoscopy CT Abdomen CT Abd, Pelvis, Chest Endoscopy MRI Liver with and with contrast Previous Procedures Appendectomy Colon Resection Feeding Tube Gallbladder removed Gastric By-Pass Other: Gastric Band Past or Present Medical Conditions Aortic Valve Disorder IBS HIV Asthma C.O.P.D Colon cancer Hepatitis High blood pressure Mitral Valve Prolapse/MR GERD Pacemaker Family Medical History No knowledge of family history No family history of Barrett's Esophagus Colitis, Unspecified Colon Cancer Liver Disease Colon Polyps
Page 3 of 6 Health Status Deceased/At Age Cause of Death Diagnoses Inflammatory Bowel Disease Chronic Liver Disease Pancreatic Cancer Barrett's Esophagus Colon Polyps Colon Cancer Other: Social History Occupation: Number of Children: Marital Status Single Married Divorced Separated Widowed Civil Union Unknown Other Alcohol Type Quantity Number Frequency Beer Wine Liquor Caffeine soda tea coffee energy drinks chocolate 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 Started Quit Quantity Frequency Cigarettes Cigarettes / Day Drug Use Type Quantity Number Frequency Marijuana
Page 4 of 6 Cocaine Exercise Type Quantity Number Frequency Walking Swimming Other
Page 5 of 6 Review Of Systems Constitutional recent fever difficulty sleeping fatigue loss of appetite weight gain weight loss Integumentary rashes cancer tattoos allergies jaundice Hematologic/Lymphatic anemia blood transfusions bleeding problems Eyes vision problems glaucoma ENMT hard of hearing nose bleeds allergies/hay fever dentures difficulty swallowing dizziness sore throat Cardiovascular chest pain palpitations heart surgery high blood pressure irregular heart beat Genitourinary pain or burning with urination difficulty with urination blood in urine kidney stones dark urine Endocrine frequent thirst diabetes thyroid disease Musculoskeletal arthritis gout Neurological weakness numbness seizures headaches Allergic/Immunologic HIV exposure persistent infections Gastrointestinal abdominal pain abdominal swelling change in bowel habits constipation diarrhea gas heartburn jaundice nausea rectal bleeding stomach cramps vomiting difficulty swallowing vomiting blood black/bloody bowel movements burning in throat stomach ulcers h.pylori bacteria colon polyps colon cancer crohn's or ulcerative colitis liver disease hepatitis a hepatitis b hepatitis c Psychiatric anxiety depression difficulty sleeping Respiratory cough coughing blood short of breath wheezing emphysema asthma Pharmacy Name Address Phone
Page 6 of 6 Consent to Import Medication History I consent to obtaining a history of my medications purchased at pharmacies. Yes No Consent to Share Data I consent to having my medical and demographic information shared with other health care entities. Yes No Reminder Preference I would like to receive preventive care and follow up care reminders. Yes No Reviewed with Patient Parent Guardian Not Present Signature Signature Date