Patient Interview Form

Patient Name

Date of Birth

Today’s Date

Consult requested by Dr.

for

Race

Ethnicity

Hispanic or Latino Not Hispanic or Latino Patient declines to provide information

Preferred Language

English Spanish Other

Contact Preference

Home phone / voice mail

Work phone / voice mail

Cell phone / voice mail

Allergies

No Known Drug Allergies

Are you allergic to Latex?

Yes No

I am allergic to

Current Medications

Add Medication

Diagnostic Studies / Tests

Colonoscopy

Upper Endoscopy (EGD)

Blood Tests

CAT Scan

EKG

Liver Biopsy

Stool Occult Blood Test

Ultrasound

X-Rays

Other

Previous Procedures

Please indicate any of the following procedures or surgeries you have had:

NONE

Appendectomy – When

Heart Bypass – When

Cardiac Stents – When

Pace Maker – When

Defibrillator – When

Stomach/Bowel/Colon – When

Gallbladder Removed: When

Uterus/Tubes/ Ovaries – When

Gastric Bypass – When

Other procedures / surgeries not listed above

Past or Present Medical Conditions

Please check the conditions you currently experience or have had in the past:

NONE

Social History

Occupation

Marital Status

Single Married Divorced Separated Widowed Civil Union Unknown Other

Alcohol

NONE

Add new row

Caffeine

NONE

Add new row

Tobacco

Smoking Status

Current every day smoker Smoker, current status unknown Current some day smoker Former smoker Unknown if ever smoked Never Smoker

Type

Started

Quit

Quantity

Frequency

Drug Use

NONE

Used IV drugs in the past Used other drugs in the past Use recreational drugs now

Family Medical History

No Knowledge of family history

Do you have a family history of:

Celiac Sprue

Yes No

Colon Cancer

Yes No

Colon Polyps

Yes No

Inflammatory Bowel Disease

Yes No

Liver Disease

Yes No

Ulcer Problems

Yes No

Diagnosis - FAMILY HISTORY

Review of Systems

Do you experience any of the following?

CARDIOVASCULAR

NONE

Chest pain

Yes No

Palpitations

Yes No

Shortness of breath

Yes No

Swelling of ankles / feet

Yes No

CONSTITUTIONAL

NONE

Fatigue

Yes No

Fever

Yes No

Weight gain

Yes No

Weight loss

Yes No

Problems with anesthesia or sedation

Yes No

EARS/NOSE/THROAT/MOUTH

NONE

Hearing loss

Yes No

Mouth sores

Yes No

Ringing in ears

Yes No

ENDOCRINE

NONE

Excessive thirst

Yes No

Excessive urination

Yes No

Cold intolerance

Yes No

Heat intolerance

Yes No

EYES

NONE

Blurred vision

Yes No

Glaucoma

Yes No

GASTROINTESTINAL

NONE

Abdominal pain

Yes No

Belching

Yes No

Black, tarry stools

Yes No

Bloating

Yes No

Blood in stool

Yes No

Change in bowel habits

Yes No

Constipation

Yes No

Diarrhea

Yes No

Difficulty swallowing

Yes No

Heartburn

Yes No

Nausea

Yes No

Poor appetite

Yes No

Rectal bleeding

Yes No

Regurgitation

Yes No

Stomach cramps

Yes No

Vomiting

Yes No

GENITOURINARY

NONE

Burning with urination

Yes No

Blood in urine

Yes No

Are you or could you possibly be pregnant?

Yes No

HEMATOLOGIC/ LYMPHATIC

NONE

Anemia

Yes No

Blood transfusion in the past

Yes No

Easy bruising

Yes No

Prolonged bleeding

Yes No

SKIN

NONE

Itching

Yes No

Rashes

Yes No

MUSCULOSKELETAL

NONE

Back pain

Yes No

Joint pain

Yes No

Joint swelling

Yes No

Muscle pain

Yes No

Muscle weakness

Yes No

NEUROLOGICAL

NONE

Frequent headaches

Yes No

Numbness or tingling

Yes No

Seizures

Yes No

Stroke

Yes No

PSYCHIATRIC

NONE

Anxiety

Yes No

Depression

Yes No

Memory loss or confusion

Yes No

RESPIRATORY

NONE

Coughing

Yes No

Spitting up blood

Yes No

Wheezing

Yes No

Pharmacy

Name

Phone Number

If necessary, your medical information can be released to someone other than yourself. Please list names of authorized people:

Spouse

Yes No

Parent

Yes No

Other Names: (Please list relationship such as daughter, son, boyfriend, girlfriend, fiancé, sister, etc.)

Patient Signature - All information contained on these patient history forms is true and correct to the best of my belief.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

Your information will be encrypted.