Personal/Family History
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Provider Name
Patient Information
*
Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.
Birth Month
January
February
March
April
May
June
July
August
September
October
November
December
Birth Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Birth Year
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Gender
Male
Female
Patient Medical History
Mark all conditions that
you
have had. If you have had none in a category, mark
None
.
Gastrointestinal Conditions
Celiac Disease or Sprue
Hiatal Hernia
Anal Fissure
Hemorrhoids
Gastrointestinal Bleeding
Bowel Obstruction
Colon Polyps
Hepatitis A
Irritable Bowel Syndrome
Acid Reflux/GERD
Diverticulitis
Hepatitis B
Yellow Skin and/or Jaundice
Cirrhosis
Diverticulosis
Hepatitis C
Stomach Ulcer or Duodenal Ulcer
Barrett's Esophagus
Crohn's Disease
Esophageal Structure or Narrowing
Chronic Constipation
Ulcerative Colitis
Helicobacter Pylori (H. Pylori)
Pancreatitis
Alcohol Abuse
None
Other
Non-Gastrointestinal Conditions
Congestive Heart Failure
Kidney Disease
Asthma
Lupus
Sleep Apnea
Seizure Disorder
Diabetes
Stroke
Heart Disease/Heart Attack
Multiple Sclerosis
Blood Clots
Anemia
Glaucoma
Bleeding Disorder
HIV Positive
Arthritis
Abnormal Heartbeat/Palpitations
High Blood Pressure
Fibromyalgia
High Cholesterol
Emphysema or COPD
Thyroid Disease
None
Cancer
Esophageal
Skin
Liver
Mouth / Throat
Stomach
Lung
Colon or Rectal
Blood (e.g. Leukemia)
Pancreatic
Ovarian
Uterine
Prostate
None
None
Other
Family History
Please mark if a
relative
has had any of the following.
Family History Unknown
Adopted
Have any of your blood relatives had
Colorectal Cancer
?
Mother
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80+
Father
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80+
Sister
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80+
Brother
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80+
Daughter
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80+
Son
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80+
Other
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80+
Have any of your blood relatives had
Colon Polyps
?
Mother
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80+
Father
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80+
Sister
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80+
Brother
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80+
Daughter
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80+
Son
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80+
Other
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80+
Mental Illness
Celiac Disease
Blood Clots
Stroke
Prostate Cancer
Breast Cancer
Pancreatitis
Diabetes
Stomach Cancer
Alcohol Abuse
Liver Failure
Sickle Cell
Bleeding Disorder
Liver Cancer
Gallstones
Hemochromatosis
Heart Attack
Hepatitis B
Autoimmune Hepatitis
Crohn's Disease
Hypertension
Hepatitis C
Irritable Bowel Syndrome
Ulcerative Colitis
Ulcer Disease
Other
Cirrhosis
Other Cancer
Tuberculosis (TB)
Ovarian Cancer
Uterine Cancer
None
Currently Active Symptoms, Tests & Other Conditions
Select all that apply. If you have no symptoms in a category, select
None
.
General
Lack of appetite
Night sweats
Unintentional weight loss (over 10 lbs)
Tiredness
Fever
None
Head, Ears, Eyes, Nose & Throat
Wear glasses
Hoarseness
Headache
Wear contacts
Decreased hearing
None
Cardiovascular
Swelling of hands or feet
Leg cramps
Fainting / blacking out
Chest pain
None
Genitourinary
Change in urinary stream
Pelvic pain
Painful urination
Blood in urine
None
Neurological
Dizziness
Loss of consciousness
Seizure
Fainting
Weakness in extremities
Difficult speech
None
Endocrine
Cold intolerance
Heat intolerance
Frequent urination
None
Musculoskeltal
Physical disability
Joint stiffness
Backache
None
Skin
Rash
Itching
None
Respiratory
Chronic cough
Difficulty breathing
Wheezing
None
Psychiatric
Suicidal thoughts
Depression
Anxiety
None
Blood
Easy bruising
None
Breast
Breast pain
Breast mass
None
Gastrointestinal
Nausea
Abdominal swelling
Vomiting blood
Belching
Diarrhea
Food / milk intolerance
Abdominal pain
Black stool
Bloating
Get full quickly at meals
Painful swallowing
Laxative use
Vomiting
Change in bowel habits
Difficulty swallowing
Blood in stool
Constipation
Pain with bowel movement
Incontinence of stool
Gas / flatulence
Heartburn
None
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:
Personal and Social History
Do you live alone?
Yes
No
Alcohol Use
Do you consume alcohol?
Never
In the past
Currently
Average number of drinks per week (now or in the past)?
7 or less
8-14
15 or more
Tobacco Use
How would you describe your cigarette smoking?
Never
Currently
(every day)
In the past
Currently
(some days)
How many packs per day do you (or did you) smoke?
Less than 1
1-2
More than 2
How many years have you (or did you) smoke?
5 or less
6-10
More than 10
Do you use other tobacco products?
Never
In the past
Currently
Caffeine Use
How many caffeinated beverages do you consume per day?
None
Occasional
1-2
3-5
More than 5
Other
IV drug use or other recreational drug use?
Never
In the past
Currently
Have you engaged in high risk behavior for sexually transmitted diseases (anal sex, unprotected sex, multiple partners)?
Never
In the past
Currently
Have you ever had a blood transfusion?
Yes
No
Have you had any recent foreign travel?
Yes
No
Do you have any body piercings?
Yes
No
Do you have any tattoos?
Yes
No
Surgeries
Please mark all surgeries you have had including the date.
Lysis of Adhesions
Hip Replacement
Tonsillectomy
Brain Surgery
Pacemaker Placement
Stomach Resection
Stomach Ulcer
Aortic Aneurysm Repair
Knee Replacement
Appendectomy
Coronary Bypass (Open Heart)
Breast Augmentation
Colon Resection
Automatic Cardiac Defibrillator
Hiatal Hernia Surgery
Kidney Transplant
Heart Valve Replacement
Gallbladder Removal
Mastectomy
Cardiac Stent
Gastric Bypass/Lap Band
Liver Transplant
Shoulder Surgery
Back Surgery
Hysterectomy
C-Section
Prostate
No Surgeries
No Surgeries
Other
Other Past Operations or Medical Problems
...not noted elsewhere in this form.
Allergies
Please select any of these allergies you have.
Contrast or Iodine Allergy
Latex Rubber Allergy
Anaphylactic or Other Reaction to Anesthesia
Medication Allergies
Please list the medications or injections that have given you bad reactions. If possible, include your reactions.
(e.g., hives, welts, rash, itching, headaches, nausea, diarrhea, passed out, shock, shortness of breath)
1.
2.
3.
4.
Prescription Medications
What prescription medications are you currently taking?
(Alternatively bring in an accurate list with you)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Over-The-Counter Medications
What over-the-counter medications are you currently taking?
(e.g., Aspirin, Motrin, Tagamet-HB, Vitamins, etc.)
1.
2.
3.
4.
5.
Physicians
Which physician referred you?
Who is your primary care doctor?
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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 421
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