PATIENT HISTORY FORM

Name:

Date:

AGE:

HEIGHT:

WEIGHT:

REFERRING DOCTOR:

I. MAIN COMPLAINT – THE MAIN REASON YOU ARE SEEING THE DOCTOR TODAY

II. OTHER SYMPTOMS YOU ARE HAVING: PLEASE SELECT YES OR 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

Fever

Yes No

Lower Abdominal Pain

Yes No

Painful Swallowing

Yes No

Nausea

Yes No

Upper Abdominal Pain

Yes No

Weight Loss

Yes No

Other:

What specific concerns or questions would you like the physician to address?(Fear of cancer, Hepatitis, etc.):

III. REVIEW OF SYSTEMS – IF YOU ARE CURRENTLY EXPERIENCING: PLEASE SELECT YES OR NO

CONSTITUTIONAL

Other:

EARS-NOSE-MOUTH-THROAT

Other:

RESPIRATORY

Cough

Yes No

Shortness of Breath

Yes No

Wheezing

Yes No

Other:

CARDIOVASCULAR

Chest Pain

Yes No

Edema

Yes No

Palpitation

Yes No

Other:

GENITOURINARY

Frequent Urination

Yes No

Painful Urination

Yes No

Other:

GYNECOLOGY

Is there any chance you could be pregnant?

Yes No

Other:

MUSCULOSKELETAL

Back Pain

Yes No

Joint pain

Yes No

Other:

NEUROLOGICAL

Weakness on either side

Yes No

Headaches

Yes No

Other:

PSYCHIATRIC

Anxiety Disorder

Yes No

Depression

Yes No

Other:

ENDOCRINE

Dry Skin

Yes No

Heat/Cold Intolerance

Yes No

Other:

HEMATOLOGIC / LYMPHATIC

Anemia

Yes No

Bleeding/Bruising

Yes No

Tendency

Yes No

Enlarged Lymph Nodes

Yes No

Other:

IV. GENERAL MEDICAL HISTORY

If Yes, give date:

Diabetes

Yes No

High Blood Pressure

Yes No

Congestive Heart Failure

Yes No

Heart Disease

Yes No

Heart Valve Replacement Disease

Yes No

Heart Stents

Yes No

If Yes, give date:

Last Stress Test And Results:

Heart Murmur

Yes No

Mitral Valve Prolapse

Yes No

Lung Disease

Yes No

Heavy Snoring

Yes No

GI PAST MEDICAL HISTORY

HAVE YOU EVER HAD A COLONOSCOPY?

Yes No

Other:

PAST SURGICAL HISTORY Please list all operations you have had:

Do you have sleep apnea

Yes No

Do you use a C-PAP Machine

Yes No

If Yes, (*Please bring your machine with you for your procedure)

Have you ever experience an adverse reaction (low blood pressure/heart rate, difficulty breathing, etc.) to intravenous sedation or anesthesia?

Yes No

If yes, for what operation/procedure:

Date of procedure

Have you ever had a Blood Transfusion?

Yes No

If yes, when?

Radiation/Chemo

Yes No

If yes, when?

Drug Allergies?

Yes No

Are you allergic to eggs?

Yes No

Are you allergic to Lidocaine?

Yes No

Are you allergic to soy?

Yes No

Are you allergic to latex?

Yes No

Please list:

Are you currently taking prescription or over the counter medication?

Yes No

List all medications you are taking (prescription and non-prescription) Please list all pain medication, sleeping pills or nerve pills you are taking even if you only take them occasionally.

Medicine:

Dosage:

Time/Day:

Add New Medication

Do you use alcohol?

Yes No

Amount:

Frequency:

Do you use tobacco?

Yes No

Packs per day:

Do you use drugs?

Yes No

Type:

Frequency:

Do you have a family history of the following

High Blood Pressure

Yes No

Who:

Type(if known?)

Early Heart Disease

Yes No

Who:

Type(if known?)

Diabetes

Yes No

Who:

Type(if known?)

Cancer

Yes No

Who:

Type(if known?)

Colon Polyps

Yes No

Who:

Type(if known?)

Colon Cancer

Yes No

Who:

Type(if known?)

Inflammatory Bowel Disease

Yes No

Who:

Type(if known?)

Liver Disease

Yes No

Who:

Type(if known?)

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