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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