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ASSOCIATES IN GASTROENTEROLOGY & LIVER DISEASEHEALTH HISTORY FORMName_______________________________________________________ Date__________________________Date of Birth________________________ Age_______________ Referred By___________________________Height_______________ Weight_______________ Primary Care Doctor _______________________________Ethnicity: FORMCHECKBOX Not Hispanic/Latino FORMCHECKBOX Hispanic/Latino FORMCHECKBOX Declined FORMCHECKBOX Unknown Race:_____________PHARMACY (name, location, phone/fax number) __________________________________________________REASON FOR YOUR VISIT TO THE OFFICE FORMCHECKBOX Heartburn FORMCHECKBOX Nausea FORMCHECKBOX Diarrhea FORMCHECKBOX Hemoccult + stools FORMCHECKBOX Difficulty swallowing FORMCHECKBOX Vomiting FORMCHECKBOX Constipation FORMCHECKBOX Anemia FORMCHECKBOX Painful swallowing FORMCHECKBOX Upper abdominal pain FORMCHECKBOX Narrowed stools FORMCHECKBOX Decreased appetite FORMCHECKBOX Regurgitation FORMCHECKBOX Lower abdominal pain FORMCHECKBOX Rectal pain/itching FORMCHECKBOX Weight loss FORMCHECKBOX Excessive belching FORMCHECKBOX Bloating FORMCHECKBOX Rectal bleeding FORMCHECKBOX Jaundice FORMCHECKBOX Chest pain FORMCHECKBOX Gas/flatulence FORMCHECKBOX Black stools FORMCHECKBOX Screening colonoscopy FORMCHECKBOX Abnormal liver tests FORMCHECKBOX Abnormal ultrasound or CAT scan FORMCHECKBOX Personal history of colon polyps/cancer FORMCHECKBOX Family history of colon polyps/cancer FORMCHECKBOX Other__________________________________________________________________________________Have you had any of the following done to evaluate for the cause of your symptoms? FORMCHECKBOX Laboratory tests or blood work FORMCHECKBOX Radiology imaging (x-rays, ultrasounds, CAT scans, MRIs, barium studies) FORMCHECKBOX Endoscopies (upper GI scope/EGD, ERCP, colonoscopy) FORMCHECKBOX Emergency room visitsIf possible, we would greatly appreciate it if you would please bring any relevant medical records with you or have them faxed to our office in advance of your visit – Fax (847) 295-1574.What medications have you tried to treat your symptoms with (non-prescription and prescription)?____________________________________________________________________________________________________________________________________________________________________________________ALLERGIES FORMCHECKBOX NONE FORMCHECKBOX Demerol FORMCHECKBOX Iodine dye FORMCHECKBOX Morphine FORMCHECKBOX Propofol FORMCHECKBOX Surgical tape FORMCHECKBOX Codeine FORMCHECKBOX Fentanyl FORMCHECKBOX Latex FORMCHECKBOX Penicillin FORMCHECKBOX Sulfa FORMCHECKBOX Versed FORMCHECKBOX Other__________________________________________________________________________________Any prior difficulties with sedation or anesthesia (nausea/vomiting, high tolerance, other)? FORMCHECKBOX Yes FORMCHECKBOX No__________________________________________________________________________________________MEDICATIONSPlease be certain to include birth control pills, hormones, and ALL non-prescription medications, such as anti-inflammatories (i.e. aspirin, advil, motrin, aleve, ibuprofen), acid blockers (i.e. zantac, pepcid, tagamet, prilosec OTC), topical hemorrhoidal creams (i.e. anusol, preparation H), vitamins, and herbal supplements.MedicationDosageFrequencyPAST MEDICAL ILLNESSESGastrointestinal FORMCHECKBOX Heartburn/GERD FORMCHECKBOX Gallstones FORMCHECKBOX Diverticulitis FORMCHECKBOX Anal fistula FORMCHECKBOX Hiatal hernia FORMCHECKBOX Pancreatitis FORMCHECKBOX Ulcerative colitis FORMCHECKBOX Anal fissure FORMCHECKBOX Gastritis FORMCHECKBOX Irritable bowel (IBS) FORMCHECKBOX Crohn’s disease FORMCHECKBOX Stool incontinence FORMCHECKBOX H. pylori FORMCHECKBOX Spastic colitis FORMCHECKBOX Colon polyps FORMCHECKBOX Abnormal liver tests FORMCHECKBOX Ulcer FORMCHECKBOX Lactose intolerance FORMCHECKBOX Colon cancer FORMCHECKBOX Fatty liver FORMCHECKBOX Celiac disease FORMCHECKBOX Diverticulosis FORMCHECKBOX Hemorrhoids FORMCHECKBOX Hepatitis FORMCHECKBOX CirrhosisCardiovascular FORMCHECKBOX High blood pressure FORMCHECKBOX Heart attack FORMCHECKBOX PVCs FORMCHECKBOX Mitral valve prolapsed FORMCHECKBOX High cholesterol FORMCHECKBOX Atrial fibrillation FORMCHECKBOX Rhythm disorder FORMCHECKBOX Rheumatic fever FORMCHECKBOX Angina FORMCHECKBOX Tachycardia FORMCHECKBOX Heart murmur FORMCHECKBOX Congestive heart failurePulmonary FORMCHECKBOX Sleep apnea FORMCHECKBOX Emphysema (COPD) FORMCHECKBOX Pulmonary embolism FORMCHECKBOX Lung cancer FORMCHECKBOX Asthma FORMCHECKBOX Pneumonia FORMCHECKBOX Sarcoidosis FORMCHECKBOX Pleurisy Neuropsychiatric FORMCHECKBOX Stroke FORMCHECKBOX Migraines FORMCHECKBOX Dementia FORMCHECKBOX Eating disorder FORMCHECKBOX TIA (mini-stroke) FORMCHECKBOX Chronic headaches FORMCHECKBOX Depression FORMCHECKBOX ADHD FORMCHECKBOX Multiple sclerosis FORMCHECKBOX Parkinson's disease FORMCHECKBOX Anxiety FORMCHECKBOX Hormonal mood disorder FORMCHECKBOX Seizures FORMCHECKBOX Myasthenia gravis FORMCHECKBOX Bipolar disorder Hematologic FORMCHECKBOX Anemia FORMCHECKBOX Blood clot FORMCHECKBOX Hodgkin's disease FORMCHECKBOX Leukemia FORMCHECKBOX Blood transfusion FORMCHECKBOX Hemochromatosis FORMCHECKBOX Lymphoma FORMCHECKBOX Myelodysplastic syndromeEndocrine FORMCHECKBOX Diabetes FORMCHECKBOX Hyperthyroidism FORMCHECKBOX Goiter FORMCHECKBOX Pituitary problem FORMCHECKBOX Hypothyroidism FORMCHECKBOX Thyroid nodule FORMCHECKBOX Thyroid cancer FORMCHECKBOX Adrenal problem Genitourinary FORMCHECKBOX Kidney disease FORMCHECKBOX Urinary tract infections FORMCHECKBOX Ovarian cyst(s) FORMCHECKBOX Abnormal Pap smears FORMCHECKBOX Kidney stones FORMCHECKBOX Bladder incontinence FORMCHECKBOX Ovarian cancer FORMCHECKBOX Cervical cancer FORMCHECKBOX Kidney tumors/cysts FORMCHECKBOX Prostate hypertrophy FORMCHECKBOX Uterine fibroids FORMCHECKBOX Endometriosis FORMCHECKBOX Bladder cancer FORMCHECKBOX Prostate cancer FORMCHECKBOX Uterine cancerBreast FORMCHECKBOX Fibrocystic breast changes FORMCHECKBOX Breast cancerMusculoskeletal FORMCHECKBOX Osteoarthritis FORMCHECKBOX Osteoporosis FORMCHECKBOX Fibromyalgia FORMCHECKBOX Lupus FORMCHECKBOX Rheumatoid arthritis FORMCHECKBOX Osteopenia FORMCHECKBOX Polymyalgia rheumatic FORMCHECKBOX GoutEyes, Ears, Nose, and Throat FORMCHECKBOX Glaucoma FORMCHECKBOX Macular degeneration FORMCHECKBOX Allergic rhinitis FORMCHECKBOX Oral thrush FORMCHECKBOX Cataracts FORMCHECKBOX Retinal detachment FORMCHECKBOX Sinusitis FORMCHECKBOX Sjogren’sDermatologic FORMCHECKBOX Eczema FORMCHECKBOX Vitiligo FORMCHECKBOX Raynaud's syndrome FORMCHECKBOX Squamous cell skin cancer FORMCHECKBOX Psoriasis FORMCHECKBOX Alopecia FORMCHECKBOX Basal cell skin cancer FORMCHECKBOX MelanomaOncologic FORMCHECKBOX Any other malignant tumors not previously mentioned:_______________________________________Infectious Disease FORMCHECKBOX Any communicable disease, such as hepatitis, HIV, or sexually transmitted disease?___________________ FORMCHECKBOX Any other hospitalizations or medical conditions not previously mentioned ____________________________________________________________________________________________________________________PREVIOUS SURGERIES AND PROCEDURES FORMCHECKBOX Gallbladder FORMCHECKBOX C-section FORMCHECKBOX Vasectomy FORMCHECKBOX Foot surgery FORMCHECKBOX Appendix FORMCHECKBOX Tubal ligation FORMCHECKBOX Prostate surgery FORMCHECKBOX Stent/angioplasty FORMCHECKBOX Groin hernia repair FORMCHECKBOX Total hysterectomy FORMCHECKBOX Tonsillectomy FORMCHECKBOX Heart bypass surgery FORMCHECKBOX Bowel obstruction FORMCHECKBOX Partial hysterectomy FORMCHECKBOX Sinus surgery FORMCHECKBOX Heart valve surgery FORMCHECKBOX Adhesion surgery FORMCHECKBOX Ovarian surgery FORMCHECKBOX Cataract surgery FORMCHECKBOX Pacemaker FORMCHECKBOX Colon resection FORMCHECKBOX Uterine ablation FORMCHECKBOX Lasik eye surgery FORMCHECKBOX Defibrillator FORMCHECKBOX Hemorrhoid surgery FORMCHECKBOX Cone biopsy/LEEP FORMCHECKBOX Arthroscopy FORMCHECKBOX Carotid surgery FORMCHECKBOX Anti-reflux surgery FORMCHECKBOX Benign breast biopsy FORMCHECKBOX Knee replacement FORMCHECKBOX Vascular surgery FORMCHECKBOX Weight loss surgery FORMCHECKBOX Lumpectomy FORMCHECKBOX Hip replacement FORMCHECKBOX Vein stripping FORMCHECKBOX D & C FORMCHECKBOX Mastectomy FORMCHECKBOX Back surgery FORMCHECKBOX Any other surgeries not previously mentioned__________________________________________________SOCIAL HISTORYMarital status FORMCHECKBOX Single FORMCHECKBOX Married FORMCHECKBOX Separated FORMCHECKBOX Divorced FORMCHECKBOX WidowedOccupation________# of Children_____________ Years of Education_____________ Preferred Language_____________________Do you use tobacco currently? FORMCHECKBOX Yes FORMCHECKBOX NoDid you ever use tobacco products? FORMCHECKBOX Yes FORMCHECKBOX NoWhen did you quit? ___________________Number of packs per day?______________How many years?_____________________Do you drink alcohol? FORMCHECKBOX Yes FORMCHECKBOX NoHow many glasses do you drink per day? ________How many glasses do you drink per week? _______Any problems with alcohol or drug use? _________Do you drink caffeine? FORMCHECKBOX Yes FORMCHECKBOX NoNumber of cups per day of caffeinated coffee?____Number of cups per day of caffeinated tea? ______Number of cups per day of caffeinated soda? _____ FAMILY HISTORYFatherMotherSonDaughterBrotherSisterGrand-motherGrand-fatherAuntUncleCousinColorectalcancerColorectalpolypsCeliacdiseaseCrohn’sdiseaseUlcerativecolitisH. pyloriHemo-chromatosisHepatitis BHepatitis CStomachcancerUterinecancerREVIEW OF SYSTEMSGeneral FORMCHECKBOX Fatigue FORMCHECKBOX Weakness FORMCHECKBOX Fever FORMCHECKBOX Night sweats FORMCHECKBOX Weight loss Eyes FORMCHECKBOX Glasses FORMCHECKBOX Vision changes FORMCHECKBOX Eye redness FORMCHECKBOX Color blindness FORMCHECKBOX ContactsEars/Nose/Throat FORMCHECKBOX Hearing loss FORMCHECKBOX Runny nose FORMCHECKBOX Mouth sores FORMCHECKBOX Tooth/gum problems FORMCHECKBOX Ringing in ears FORMCHECKBOX Nosebleeds FORMCHECKBOX Tongue sores Cardiovascular FORMCHECKBOX Chest pain FORMCHECKBOX Palpitations FORMCHECKBOX Shortness of breath with exertion or sleep FORMCHECKBOX Ankle swelling/edema FORMCHECKBOX Varicose veins FORMCHECKBOX Blue color changes in hands with coldRespiratory FORMCHECKBOX Cough FORMCHECKBOX Coughing blood FORMCHECKBOX Shortness of breath FORMCHECKBOX WheezingEndocrine FORMCHECKBOX Intolerance to cold FORMCHECKBOX Excessive sweating FORMCHECKBOX Abnormal skin pigment FORMCHECKBOX Dry skin FORMCHECKBOX Intolerance to heat FORMCHECKBOX Excessive hunger FORMCHECKBOX Abnormal body hair FORMCHECKBOX Dry hair Lymph nodes (glands) FORMCHECKBOX Swollen jaw FORMCHECKBOX Swollen neck FORMCHECKBOX Swollen underarm FORMCHECKBOX Swollen groinBones/Joints/Muscles FORMCHECKBOX Pain FORMCHECKBOX Swelling FORMCHECKBOX StiffnessSkin FORMCHECKBOX Itching FORMCHECKBOX Rash FORMCHECKBOX Bruising FORMCHECKBOX Scaling Neurologic FORMCHECKBOX Headaches FORMCHECKBOX Fainting FORMCHECKBOX Localized numbness FORMCHECKBOX Speech difficulty FORMCHECKBOX Dizziness FORMCHECKBOX Tremor FORMCHECKBOX Walking difficulty FORMCHECKBOX Memory difficulty Genitourinary FORMCHECKBOX Blood in urine FORMCHECKBOX Burning urination FORMCHECKBOX Dark urine FORMCHECKBOX Frequent urination FORMCHECKBOX Frequent urination at night FORMCHECKBOX Urinary incontinence Males: FORMCHECKBOX Slow urinary stream FORMCHECKBOX Difficulty initiating urination FORMCHECKBOX Penile discharge FORMCHECKBOX Breast enlargementFemales: FORMCHECKBOX Abnormal periods FORMCHECKBOX Menopause FORMCHECKBOX Vaginal discharge FORMCHECKBOX Breast lump(s) FORMCHECKBOX Breast pain FORMCHECKBOX Nipple discharge Patient’s or Legal Guardian’s Signature__________________________________ Date ____________________Physician’s Initials___________________________________________________ Date____________________ ................
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