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Current Symptoms
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---------- Date of Birth ----------
------- Fecha de nacimiento -------
------- Fecha de nacimiento -------
------- Fecha de Nacimiento -------
First Name
Nombre
Nombre
Nombre
Last Name
Apellido
Apellido
Apellido
Month
Mes
Mes
Mes
Day
Día
Día
Día
Year
Año
Año
Año
Gender
Género
Género
Género
January
February
March
April
May
June
July
August
September
October
November
December
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
2024
2023
2022
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
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1984
1983
1982
1981
1980
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1978
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1972
1971
1970
1969
1968
1967
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1964
1963
1962
1961
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1950
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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
Male
Female
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Provider Name
PATIENT MEDICAL HISTORY
Mark all conditions that you have had. If you have had none in a category, mark
NONE
.
GASTROINTESTINAL CONDITIONS
Acid Reflux / GERD
Diverticulitis
Hepatitis C
Alcohol Abuse
Diverticulosis
Hiatal Hernia
Anal Fissure
Esophageal Stricture/Narrowing
Intestinal Infection
Barrett's Esophagus
Gallbladder Problems
Irritable Bowel Syndrome (IBS)
Bowel Obstruction
Gastrointestinal Bleeding
Liver Failure / Cirrhosis
Celiac Disease or Sprue
Helicobacter Pylori (H. pylori)
Pancreatitis
Chronic Constipation
Hemorrhoids
Stomach Ulcer / Duodenal Ulcer
Colon Polyps
Hepatitis A
Ulcerative Colitis
Crohn's Disease
Hepatitis B
Yellow Skin / Jaundice
Other
NONE
NON-GASTROINTESTINAL CONDITIONS
Abnormal Heartbeat / Palpitations
Diabetes
Kidney Disease
Anemia
Emphysema / COPD
Lupus
Antibiotic Treatment
(Past 2 Months)
Fibromyalgia
Multiple Sclerosis (MS)
Arthritis
Hardening of the Arteries
Seizure Disorder
Asthma
Heart Disease / Heart Attack
Stroke
Bleeding Disorder
High Blood Pressure
Thyroid Disease
Blood Clots
HIV Exposure
Treatment with Blood Thinner
Congestive Heart Failure
HIV Positive
NONE
CANCER
Blood (e.g., Leukemia)
Lungs
Prostate
Breast
Mouth / Throat
Skin
Colon / Rectal
Ovarian
Stomach
Esophageal
Pancreatic
Uterine
Liver
Other
NONE
FAMILY HISTORY
Please mark if a relative has had any of the following.
Family History Unknown
Adopted
Other Family History Not Listed
Alcohol Abuse
Gallstones
Ovarian Cancer
Autoimmune Hepatitis
Heart Attack
Pancreatitis
Bleeding Disorder
Hemochromatosis
Prostate Cancer
Blood Clots
Hepatitis B
Sickle Cell
Breast Cancer
Hepatitis C
Stomach Cancer
Cancer, Other
Hypertension
Stroke
Celiac Disease
Irritable Bowel Syndrome
Tuberculosis (TB)
Cirrhosis
Liver Cancer
Ulcer Disease
Crohn's Disease
Liver Failure
Ulcerative Colitis
Diabetes
Mental Illness
Uterine Cancer
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+
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+
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?
no
yes
Have you had any of these procedures?
Colonoscopy
Date:
Location:
Flexible Sigmoidoscopy
Date:
Location:
Upper Endoscopy
Date:
Location:
ERCP
(endoscopic retrograde cholangiopancreatography)
Date:
Location:
EUS
(endoscopic ultrasound)
Date:
Location:
CT scan of abdomen or GI tract
(past 6 months)
Date:
Location:
Ultrasound of abdomen or GI tract
(past 6 months)
Date:
Location:
Mammogram
Date:
Location:
Pap Smear
Date:
Location:
Recent Laboratory Testing
Date:
Location:
SURGERIES
Please mark all surgeries you have had including the date.
Gallbladder Removal
Date:
Hernia Surgery
Date:
Lysis of Adhesions
Date:
Shoulder Surgery
Date:
Pacemaker Placement
Date:
Weight Loss Surgery
Date:
Aortic Aneurysm Repair
Date:
Hysterectomy
Date:
Coronary Artery Bypass Graft
Date:
Appendectomy
Date:
Automatic Cardiac Defibrillator
Date:
Colon Resection
Date:
Heart Valve Replacement
Date:
Kidney Transplant
Date:
Liver Transplant
Date:
Back Surgery
Date:
Hip Replacement
Date:
Brain Surgery
Date:
Gastric Resection
Date:
Stomach Ulcer
Date:
Knee Replacement
Date:
TURP
Date:
Breast Augmentation
Date:
Other
Date:
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 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 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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