Patient Medical History
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In order to notify the clinic, please enter your name and other demographic information above and enter the name
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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
2021
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
* Required Information
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
Intestinal Infection
Anal Fissure
Hiatal Hernia
Gastrointestinal Bleeding
Bowel Obstruction
Colon Polyps
Pancreatitis
Irritable Bowel Syndrome (IBS)
Acid Reflux / GERD
Diverticulitis
Hemorrhoids
Yellow Skin / Jaundice
Liver Failure / Cirrhosis
Diverticulosis
Hepatitis A
Stomach Ulcer / Duodenal Ulcer
Barrett's Esophagus
Crohn's Disease
Hepatitis B
Esophageal Stricture/Narrowing
Chronic Constipation
Ulcerative Colitis
Hepatitis C
Helicobacter Pylori (H. pylori)
Gallbladder Problems
Alcohol Abuse
Other
None
*
Non-Gastrointestinal Conditions
Congestive Heart Failure
HIV Exposure
Kidney Disease
Lupus
Hardening of the Arteries
Seizure Disorder
Diabetes
Stroke
Heart Disease / Heart Attack
Multiple Sclerosis (MS)
Blood Clots
Anemia
Treatment with Blood Thinner
Bleeding Disorder
HIV Positive
Arthritis
ABN Heartbeat / Palpitations
High Blood Pressure
Fibromyalgia
Asthma
Antibiotic Trmt in Past 2 Months
Emphysema / COPD
Thyroid Disease
None
*
Cancer
Esophageal
Blood (e.g., Leukemia)
Prostate
Lungs
Liver
Mouth / Throat
Ovarian
Pancreatic
Uterine
Breast
Colon / Rectal
Stomach
Skin
Other
None
Family History
*
Please mark if a relative has had any of the following.
Family History Unknown
Adopted
Other Family History Not Listed
Mental Illness
Irritable Bowel Syndrome
Ovarian Cancer
Liver Failure
Stroke
Prostate Cancer
Cirrhosis
Crohn's Disease
Liver Cancer
Diabetes
Stomach Cancer
Celiac Disease
Ulcerative Colitis
Heart Attack
Sickle Cell
Bleeding Disorder
Breast Cancer
Cancer, Other
Hypertension
Gallstones
Hemochromatosis
Alcohol Abuse
Blood Clots
Ulcer Disease
Hepatitis B
Autoimmune Hepatitis
Uterine Cancer
Pancreatitis
Tuberculosis (TB)
Hepatitis C
None
*
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 or more
Father
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80 or more
Sister
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80 or more
Brother
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80 or more
Daughter
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80 or more
Son
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80 or more
Other
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80 or more
*
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 or more
Father
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80 or more
Sister
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80 or more
Brother
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80 or more
Daughter
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80 or more
Son
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80 or more
Other
Yes
No
Age of Onset:
20's
30's
40's
50's
60's
70's
80 or more
Currently Active Symptoms, Tests & Other Conditions
Select all that apply. If you have no symptoms in a category, select
NONE
.
*
General
Night sweats
Fever
Unintentional weight loss (over 10 lbs)
Tiredness
Lack of appetite
None
*
Head, Ears, Eyes, Nose & Throat
Headache
Wear glasses
Glaucoma
Sleep apnea
Wear contacts
Hoarseness
Decreased hearing
None
*
Cardiovascular
Heart stent
Swelling of hands or feet
Leg cramps
Chest pain
Elevated blood pressure
Fainting / Blacking out
None
*
Genitourinary
Change in urinary stream
Pelvic pain
Blood in urine
Painful urination
Urinary frequency
None
*
Neurological
Dizziness
Loss of consciousness
Seizures
Fainting
Weakness in extremities
Difficult speech
None
*
Endocrine
Cold intolerance
Excessive thirst
Heat intolerance
Excessive urination
None
*
Musculoskeletal
Backache
Joint stiffness
Physical disability
None
*
Skin
Itching
Rash
None
*
Respiratory
Chronic cough
Difficulty breathing
Wheezing
None
*
Psychiatric
Suicidal thoughts
Depression
Anxiety
None
*
Blood
Easy bruising
None
*
Breast
Breast mass
Breast pain
None
*
Gastrointestinal
Constipation
Heartburn
Nausea
Food / Milk intolerance
Painful swallowing
Vomiting blood
Belching
Diarrhea
Get full quickly at meals
Difficulty swallowing
Abdominal pain
Black stool
Bloating
Change in bowel habits
Stool incontinence
Blood in stool
Laxative use
Vomiting
Painful bowel movement
Abdominal swelling
Gas / Flatulence
None
*
Has your stool tested positive for blood in the past 6 months?
Yes
No
Have you had any of these procedures?
Colonoscopy
Flexible Sigmoidoscopy
Upper Endoscopy
ERCP (endoscopic retrograde cholangiopancreatography)
EUS (endoscopic ultrasound)
CT scan of abdomen or GI tract (past 6 months)
Ultrasound of abdomen or GI tract (past 6 months)
Mammogram
Pap Smear
Recent Laboratory Testing
Surgeries
*
Please mark all surgeries you have had including the date.
Gallbladder Removal
Hernia Surgery
Lysis of Adhesions
Shoulder Surgery
Pacemaker Placement
Weight Loss Surgery
Aortic Aneurysm Repair
Hysterectomy
Coronary Artery Bypass Graft
Appendectomy
Automatic Cardiac Defibrillator
Colon Resection
Heart Valve Replacement
Kidney Transplant
Liver Transplant
Back Surgery
Hip Replacement
Brain Surgery
Gastric Resection
Stomach Ulcer
Knee Replacement
TURP
Breast Augmentation
Other
I have had no surgeries
Other Past Operations or Medical Problems
Not noted elsewhere in this form.
Personal and Social History
Alcohol Use
*
Do you consume alcohol?
Never
In the past
Currently
Average number of drinks per week now?
Average number of drinks per week in 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 smoke?
How many packs per day did you smoke?
less than 1
1-2
more than 2
How many years have you smoked?
How many years 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
*
Do you live alone?
Yes
No
Allergies
*
Please select any of these allergies you have.
If you have any additional medication allergies, please bring in list with reaction to your appointment.
Contrast or Iodine Allergy
Latex Rubber Allergy
Anaphylactic or Other Reaction to Anesthesia
I have no known medication allergies
Medications
If you are taking medications, please bring an accurate list at time of your appointment.
If you are not taking any medications, please indicate here:
I am not currently taking any medications
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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 460
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