Patient Information
 
 
 
 
 
 
 
 

Race

 
 
 
 
 
 
 
 

Ethnicity

 
 
 
 
 

Allergies

If you have any additional allergies not listed please mention that allergy to your provider during your visit.

 
Do you have any medication allergies?
 
 
 
 
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Do you have any food allergies?
 
 
 
 
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Do you have any environmental allergies?
 
 
 
 
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Social History

Employment status:
 
 
 
 
 

Student status:
 
 
 
 

Do you have an Advanced Directive / Living Will?
 
 

TOBACCO USE

 
How would you describe your cigarette smoking?
 
 
 
 
 
How many packs per day do you smoke?
 
 
 
 
How many years have you smoked?
 
How many packs per day do you smoke?
 
 
 
 
How many years have you smoked?
 
How many packs per day did you smoke?
 
 
 
 
How many years did you smoke?
 
Does anyone in your household smoke?
 
 
Do you use other tobacco products?
 
 
 
 

ALCOHOL USE

 
Do you consume alcohol?
 
 
 
 
What is your average number of drinks per week?
 
 
 
 
What was your average number of drinks per week?
 
 
 
 

IV drug use or other recreational drug use?
 
 
 
 

Have you had any recent foreign travel?
 
 

Do you have any body piercings?
 
 

Do you have any tattoos?
 
 
 

Gastrointestinal Conditions

Acid Reflux / GERD
 
 
Alcohol Abuse
 
 
Anal Fissure
 
 
Barrett's Esophagus
 
 
Bowel Obstruction
 
 
Celiac Disease or Sprue
 
 
Chronic Constipation
 
 
Chronic Diarrhea
 
 
Cirrhosis / Liver Failure
 
 
Colon Polyps
 
 
Crohns Disease
 
 
Diverticulitis
 
 
Diverticulosis
 
 
Gallbladder Problems
 
 
Gastrointestinal Bleeding
 
 
Hemorrhoids
 
 
Hepatitis A
 
 
Hepatitis B
 
 
Hepatitis C
 
 
Hiatal Hernia
 
 
H. Pylori
 
 
Irritable Bowel Syndrome (IBS)
 
 
Liver Failure
 
 
Pancreatitis
 
 
Stomach or Duodenal Ulcer
 
 
Ulcerative Colitis
 
 
Other Gastrointestinal condition (please specify):
 
 
 

Surgical History

Please indicate if you have had any surgeries:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other Surgery (please specify):
 
 
 
 

Your Medical History

Please indicate if you have a history of the following:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other Disease or Significant Medical Illness (please specify):
 
 
 
 

Cancer

Please indicate if you have a history of any type(s) of cancer:

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other Cancer (please specify):
 
 
 
 

Family Medical History

Please indicate which family member(s) have had these illnesses.

 
 
 
 
 
  Brother Sister Father Mother Grandfather Mother's side Grandmother Mother's side Grandfather Father's side Grandmother Father's side
Autoimmune Hepatitis
Bleeding Disorder
Blood Clots
Breast Cancer
Celiac Disease
Colon Cancer
Colon Polyps
Crohn's Disease
Diabetes Type 1
Diabetes Type 2 (adult onset)
Esophageal Cancer
Gallstones
Heart Disease
Hemochromatosis
Liver Disease
Pancreatic Cancer
Prostate Cancer
Sickle Cell
Stomach Cancer
Stomach Ulcer
Stroke
Ulcerative Colitis
Cancer (other)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

IMPORTANT: Please do not use the 'BACK' button on your browser while completing your history forms.
 
Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 1203
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.