REASON FOR VISIT

 
 

YOUR MEDICAL HISTORY

GASTROINTESTINAL CONDITIONS

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other:

NON-GASTROINTESTINAL CONDITIONS

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other:

CANCER

 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other:
 

FAMILY HISTORY

Has any of your blood relatives had Colorectal Cancer?
Age relative developed condition, if known:
       YES           NO             20's           30's           40's           50's           60's           70's           80's     
Grandparent  
Parent  
Brother / Sister  
Child  
Aunt / Uncle  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other:
 

PATIENT STATUS

 
Marital status:
 
 
 
 

 
Do you live alone?
 
 

ALCOHOL USE

 
Do you consume alcohol?
 
 
 
 
Average number of drinks per week?
 
 
 

TOBACCO USE

 
How would you describe your cigarette smoking?
 
 
 
 
 
How many packs per day?
 
 
 
 
For how many years?
 
 
 
 
 
Do you use other tobacco products?
 
 
 

 
How many caffeinated beverages do you consume per day?
 
 
 
 
 

 
Recent foreign travel?
 
 

 
IV drug use or other recreational drug use?
 
 
 
 

 
Have you engaged in high-risk behavior for sexually transmitted diseases?
(e.g., anal sex, homosexual activity, multiple sex partners, etc.)
 
 
 
 

 
Have you had a blood transfusion?
 
 

 
Do you have a tattoo(s)?
 
 

 
Do you have a body piercing(s)?
 
 
 

CURRENT CONDITIONS

Do you currently have any of these symptoms or conditions? select all that apply.
If no symptoms, select "NONE".

GASTROINTESTINAL

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Has your stool tested positive for blood?
 
 
 
Have you ever had an x-ray, CT or ultrasound of your abdomen or GI tract?
 
 

GENERAL

 
 
 
 
 
 
 
 

NEUROLOGICAL

 
 
 
 
 

CARDIOVASCULAR

 
 
 
 
 

RESPIRATORY

 
 
 
 
 
 
 
 

GENITOURINARY

 
 
 
 
 
 
 
 

ENDOCRINE

 
 
 

FEMALES

 
 
 
 
 

PSYCHOSOCIAL

 
 
 
 
 

SKIN

 
 
 
 
 
 

BONE & JOINT

 
 
 
 
 

BLOOD

 
 
 
 
 

EYES

 
 
 
 
 

EARS / NOSE / THROAT

 
 
 
 
 
 
 
Do you have an advance directive?
 
 
 
Do we have a copy?
 
 
 

SURGERIES

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other:
 

OTHER PAST MEDICAL PROBLEMS

Other:
 

PROCEDURES

Please indicate if you have had any of the following:
 
 
Date
 
Findings
 
 
Date
 
Findings
 
 
Date
 
Findings
 
 
Date
 
Findings
 

ALLERGIES

Please indicate if you have allergies to any of the following:
 
 
 
 
 
Other:
Please list any MEDICATIONS or INJECTIONS that have given you bad reactions. If possible, include your reactions
(e.g., hives, welts, rash, itching, headaches, nausea, diarrhea, fainted, shock, shortness of breath, etc.)
 
 
Please list any FOODS that have given you bad reactions. If possible, include your reactions
(e.g., hives, welts, rash, itching, headaches, nausea, diarrhea, fainted, shock, shortness of breath, etc.)
 
 

MEDICATIONS

Include PRESCRIPTION and OVER THE COUNTER medications.
(e.g., aspirin, Advil, BC Powder©, Motrin, Tagamet-HB, vitamins, supplements, herbs, etc.)
 
Name of Medication
 
Dosage
 
Frequency
 
1.
 
 
 
2.
 
 
 
3.
 
 
 
4.
 
 
 
5.
 
 
 
6.
 
 
 
7.
 
 
 
8.
 
 
 
9.
 
 
 
10.
 
 
 
11.
 
 
 
12.
 
 
 
13.
 
 
 
14.
 
 
 
15.
 
 
 
16.
 
 
 
 
Occupation:
 
 
Referring MD:
 
 
Last Menstrual Period:
 
 
Primary MD / OB-GYN:
 

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