Download Patient Information Form 1

PATIENT HISTORY FORM
Last Name:
First Name:
Date of Birth (mm-dd-yyyy)
Date of Visit (mm-dd-yyyy)
Primary Care Provider’s Name:
Referring Provider’s Name:
MI:
ARE YOU COMING IN FOR A COLONOSCOPY SCREENING? YES ( ) NO ( )
IF NO THEN WHAT IS/ARE THE COMPLAINT(S)________________________________________
______________________________________________________________________________________
Location:
Where is the pain/problem?
Quality:
Example: normal versus abnormal texture/color
Severity:
How severe on a scale of 1 to 5, 5 being worst
Duration:
How long have you had this pain/problem?
Timing:
Does the pain/problem occur at a specific time?
Context:
Where were you at the onset of this problem?
Associated signs/symptoms:
What other problems have you been having?
Modifying factors:
What makes the pain/problem worse or better?
Allergies (List all medication you are allergic to):
Medications (List all current medications):
Medication
Dose
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
_____________________________________________________________________________________
PAST GI AND MEDICAL HISTORY (check all that apply):
Y
History of stomach ulcer/s
History of duodenal ulcer/s
History of Colon cancer
Any other cancer ?
History of colon polyps
sHepatitis A
Hepatitis B
Hepatitis C
Acute Pancreatitis
Chronic pancreatitis
Ulcerative colitis
Crohn’s disease
Any other GI disease?
Diabetes
Blood transfusions
N
Y
N
Anemia
History of GI Bleeding
Bleeding disorder
Diverticulosis
Diverticulitis
Liver Problems
Cirrhosis of the liver
Gallstones
Gastric bypass
Other weight loss surgery
Hemorrhoids
Heart disease
Hives or Eczema
Comments
PAST SURGICAL HISTORY (if any):
Date
Colon
Cancer
Surgery/Procedure
FAMILY HISTORY (check all that apply):
Colon
Liver
Ulcerative
Crohn’s
Polyps
Disease
Colitis
Disease
Mother
Father
Brother
Sister
Grandfather
Grandmother
Aunt
Uncle
PAST HOSPITALIZATIONS/ILLNESSES (if any):
Hospital
Celiac
disease
Pancreatits
Date
Reason
Hospital, City, State
PATIENT SOCIAL HISTORY
MARITAL STATUS:
SINGLE MARRIED
SEPARATED
DIVORCED
WIDOWED
NATURE OF EMPLOYMENT: ____________________________________________
Sedentary, heavy-duty, etc.?
Alcohol Use:
Previous: _____ Never: _____
Rarely: _____
Regularly/Quantity: _____
Tobacco Use:
Never smoked: _____
Ex-smoker: _____
Current smoker: _____ Packs/day: _____
REVIEW OF SYSTEMS
Constitutional
Good health
Fever
Anemia
Yes
Yes
No
No
Weight loss
No
Bleed Too Long
Chronic Fatigue
Eyes
Blurred Vision
Yes
No
Glaucoma
Cardiovascular
Chest Pain
Palpitations
Yes
Yes
No
No
Shortness of Breath
Swelling of Feet
Respiratory
Wheezing
Asthma
Yes
Yes
No
No
Spitting up Blood
Frequent Cough
Yes
Gastrointestinal
Nausea
Vomiting
Constipation
Heartburn
Early Satiety
Painful BM’s
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
Loss of Appetite
Frequent Diarrhea
Fluid in Abdomen
Difficulty Swallowing
Blood in Stool
Fecal Incontinence
Yes
Integumentary
Rash
Itching
Yes
Yes
No
No
Change in Hair
Change in Nails
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
No
Yes
No
No
No
Yes
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
Yes
No
No
Ear/Nose/Mouth/Throat
Nosebleeds
Yes
Mouth Sores
Yes
Bad Breath
Yes
No
No
No
Chronic Sinus Issue
Swollen Neck Glands
Bleeding Gums
Genitourinary
Blood in Urine
Painful Periods
Yes
Yes
No
No
Frequent Urination
Burning/painful Urination
Musculoskeletal
Joint Pain
Muscle Pain
Yes
Yes
No
No
Weakness of Muscles
Muscle Cramps
No
Frequent Headaches
Yes
Yes
No
No
No
Thyroid Disorder
Neurological
Seizures
Yes
Psychiatric
Depression
Anxiety
Endocrine
Diabetes
Yes
Yes
Yes
Memory Loss/Dementia
Confusion
Yes
Yes
Yes
Yes
No
No
No
Yes
No
No
Yes
Yes
No
No
No
Yes
Yes
No
No
No
Hematological/Lymphatic
HIV / AIDS
Yes
Blood Clots:
Yes
No
No
Bleed or Bruise Easily
Swollen Glands
Yes
Yes
No
No
Allergy/Immunology
Food Allergy
Skin Reaction
No
No
Environmental Allergy
Allergy to Intravenous Dye
Yes
Yes
No
No
Yes
Yes
For Women Only
Is there a chance you could be pregnant?
What is the date of your last period?
Yes
No
________________
AUTHORIZATION & SIGNATURE
I have answered the above questions correctly (to the best of my knowledge). It is my responsibility
to inform the doctor’s office of any changes in my medical status. I also authorize the health care
staff to perform the necessary services I may need.
_____________________________
Patient/Parent/Guardian Signature
_____________________________
Date
_____________________________
Reviewer (Physician/NP)
_____________________________
Date