Choose your doctor
 
 

PATIENT MEDICAL HISTORY

Mark all conditions that you have had. If you have had none in a category, mark NONE.

GASTROINTESTINAL CONDITIONS

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

NON-GASTROINTESTINAL CONDITIONS

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

CANCER

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

FAMILY HISTORY

Mark the box if a relative has had one of the following.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Have 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+
Mother
Father
Sister
Brother
Daughter
Son
Other
 
Have any of your blood relatives had Colon Polyps?
 
Age relative developed condition, if known
  Yes No 20's 30's 40's 50's 60's 70's 80+
Mother
Father
Sister
Brother
Daughter
Son
Other
 

CURRENTLY ACTIVE SYMPTOMS, TESTS & OTHER CONDITIONS

Mark all that apply. If you have no symptoms in a category, mark NONE.

GENERAL

     
       
 

HEAD, EARS, EYES, NOSE & THROAT

   
     
       
 

CARDIOVASCULAR

     
       
 

GENITOURINARY

     
       
 

NEUROLOGICAL

     
       
 

ENDOCRINE

   
       
 

MUSCULOSKELETAL

       
 

SKIN

       
 

RESPIRATORY

       
 

PSYCHIATRIC

       
 

BLOOD

     
 

BREAST

       
 

GASTROINTESTINAL

     
     
     
     
     
     
       

Has your stool tested positive for blood in the past 6 months?
   
 
Have you had any of these procedures?
   
Colonoscopy
 
Date:
 
Findings:
   
Flexible Sigmoidoscopy
 
Date:
 
Findings:
   
Upper Endoscopy
 
Date:
 
Findings:
   
ERCP (endoscopic retrograde cholangiopancreatography)
 
Date:
 
Findings:
   
EUS (endoscopic ultrasound)
 
Date:
 
Findings:
   
CT scan of abdomen or GI tract (past 6 months)
 
Date:
 
Findings:
   
Ultrasound of abdomen or GI tract (past 6 months)
 
Date:
 
Findings:
 

SURGERIES

Please mark all surgeries you have had.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

OTHER PAST OPERATIONS OR MEDICAL PROBLEMS

(Not noted elsewhere in this form.)

REFERRING DOCTOR

 

PRIMARY DOCTOR

 
 

PERSONAL AND SOCIAL HISTORY

ALCOHOL USE

 
Do you consume alcohol?
 
 
 
 
 
Average number of drinks per week (now or in the past)?
 
 

TOBACCO USE

 
How would you describe your cigarette smoking?
 
 
 
 
 
 
 
 
How many pack per day do you (or did you) smoke?
 
 
 
 
 
How many years have you (or did you) smoke?
 
 
 
 
 
Do you use other tobacco products?
 
 

CAFFEINE USE

 
How many caffeinated beverages do you consume per day?
 
 
 
 
 
 

OTHER

 
IV drug use or other recreation drug use?
 
 
 
 
 
Have you engaged in high risk behavior for sexually transmitted diseases (anal sex, unprotected sex, multiple partners)?
 
 
 
 
 
Have you ever had a blood transfusion?
   
 
 
 
Have you had any recent foreign travel?
   
 
 
 
Do you have any body piercings?
   
 
 
 
Do you have any tattoos?
   
 
 
 
Do you live alone?
   
 

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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189 (D)
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.