Home » Clinical Gastrointestinal Associates
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HEALTH HISTORY FORM
|NAME | |DOB | |
|Reason for visit: |Today's date |
Medication allergies
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Medications
|NAME |DOSE |FREQUENCY |
| | | |
| | | |
| | | |
| | | |
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|Social History |Smoking y/n |Alcohol y/n |Illegal drugs y/n |
FAMILY HISTORY
|Blood clots | |Colon cancer/polyps | |Crohn's disease | |
|Heart disease | |Stroke | |Celiac disease | |
|Diabetes | |High blood pressure | |Ulcerative colitis | |
|cancer | |Liver disease | |Other: | |
SURGICAL HISTORY (name and date)
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MEDICAL HISTORY
|emphysema | |Blood disorder | |Hepatitis | |
|Liver disease | |Stroke/ TIA | |Heart attack | |
|Heart failure | |Atrial fibrillation | |Colon polyp | |
|Intestinal bleed | |Ulcer | |High blood pressure | |
|Diabetes | |Kidney failure | |High cholesterol | |
|Others-list | | | | | |
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