Date____________________________



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 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: Father_______Mother______Son______Daughter_______Grandpa______GrandMa_______Uncle_______Aunt_________

Colon Polyps: Father_______Mother______Son______Daughter_______Grandpa______GrandMa_______Uncle_______Aunt_________

Colitis: Father_______Mother______Son______Daughter_______Grandpa______GrandMa_______Uncle_______Aunt_________

Crohn’s: Father_______Mother______Son______Daughter_______Grandpa______GrandMa_______Uncle_______Aunt_________

Liver Disease: Father_______Mother______Son______Daughter_______Grandpa______GrandMa_______Uncle_______Aunt_________

Pancreas cancer: Father_______Mother______Son______Daughter_______Grandpa______GrandMa_______Uncle_______Aunt_________

StomachUlcer: Father_______Mother______Son______Daughter_______Grandpa______GrandMa_______Uncle_______Aunt_________

Stomach Cancer: Father_______Mother______Son______Daughter_______Grandpa______GrandMa_______Uncle_______Aunt_________

Current Illnesses of Family Members (if deceased -age’s and cause) :

Father ______________________________________ Mother _________________________________________________________________

Brothers ______________________________________ Sisters __________________________________________________________________

Uncles/Aunts ___________________________________ Grandparents_____________________________________________________________

Children _______________________________________ 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 _____ ______________________________________________

(ChronicBronchitis/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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