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Pezzone Gastroenterology Associates New Patient Information Your Name:___________________________ Your Birth date:________________________ Manifold Professional Building #3 88 Wellness Way Washington, PA 15301 phone: 724-503-4637 fax: 724-503-4429 DrPezzone.com This form is to help your doctor give you better health care. It is completely confidential and will be part of your medical record. Please write your name on every page! Would you say in general your health is: Excellent Very Good Good Fair Poor Rather not answer Unsure Thinking about your health for how many days in the past 30 days, was your: Number of days 1....physical health not good (including injury and pain) 2....emotional health not good (including stress, depression and problems with emotions) 3. How many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work or recreation? Medication Allergies List All of the Medications You Take Now Dose (mg) Frequency (times per day) Include medicines, food, environmental or any other Chief Complaint / Reason for today's visit Page 1 of 5 PATIENT HISTORY Your Name________________________ Operations or serious illnesses Month/Year Reason Hospitalized? YES NO 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) Cancer: Body part / Year 1) Have you ever had or do you have? Hospital / Doctor's Office where you received treatment Name: Year Address: Surgery 2) Name: Year Address: Surgery Name: 3) Year FAMILY HISTORY Father Mother BrotherSister BrotherSister BrotherSister BrotherSister BrotherSister Spouse/Partner Page 2 of 5 Address: Surgery Present Age Age of Death Chemotherapy Biotherapy Phone: Radiation Radiation Implants Phone: Chemotherapy Biotherapy Radiation Phone: Radiation Implants Chemotherapy Biotherapy Radiation Radiation Implants Present Health or Cause of Death SYMPTOMS Check ALL you are currently experiencing: Gastrointestinal Respiratory Your Name________________________ __Trouble Sleeping/Nightmares __Loss of Appetite __Stop breathing while sleeping __Lonely/Depressed __Heartburn or Indigestion __Frequent cough __Work/Family Problems __Stomach discomfort, cramping, pain __Cough that produces blood __Tire Easily __Frequent Nausea/Vomiting __Difficulty breathing or catching breath __Worried about Family Matters __Recurrent Diarrhea __Wear oxygen at home __Physical, emotional, verbal abuse __Constipation Genitourinary/Sexual/Intimacy __Concerns how illness will affect __Bloody Stools __Reproductive Concerns your finances __Black, tarry stools __Sexual Abuse Endocrine __Difficulty Swallowing/Chewing __Difficulty Urinating __Thyroid Problems __Frequent/Painful Urination __Blood Sugar Problems __Recent Weight Loss (Amount____) __Recurrent Bladder Infection __Excessive Sweating __Recent Weight Gain (Amount____) __Nipple Discharge __Difficulty Chewing or Swallowing __Change in Breast Size __Sores/Rashes __Food Supplements __Breast Lump/Pain __Changes in Moles __Female: Vaginal Itching __Change in Skin Color Nutritional Data (vitamins/minerals/herbs) Integumentary/Infectious __Diet Type (Regular or Restricted) HEENT __Number of meals a day _______ __Vision Loss __Fevers __Do you drink caffeinated drinks? __Hearing Loss __Night Sweats YES NO __Mouth Ulcers/Sores __Excessive Itching How many ounces a day?_____ __Dental Problems __Do you drink water? YES NO How many ounces a day? Hematologic/Lymphatic __Frequent Infections Prosthetic Devices __Hoarseness __Eye Glasses/Contacts __Nosebleeds __Dentures Musculoskeletal __Pacemaker __Difficulty Walking __Artificial Limb (Type_________) __Easy Bleeding/Bruising __Joint Aches or Stiffness __Implants (Type_________) __Blood Clots ____________ Location __Cramping __Pacemaker/Defibrillator __Ankle Swelling __Ankle or Other Joint Swelling __Anemia __Need Help With: Do you have a catheter, tube or port __Blood Problem Eating Dressing Walking in your arm, chest or abdomen for __Swelling of Glands __Swelling of Hands/Feet Neurological/psych/Social Access Devices drawing blood, receiving medication __Difficulty Concentrating or removing fluid? __Frequent Headaches Yes No __High Blood Pressure __Dizziness/Fainting If Yes, Last used_______________ __Rapid/Irregular Heart Beat __Numbness Hands or Feet __Heart Murmur __Memory Changes __Chest Pain __Feeling Overwhelmed __Leg Cramps __Anxious/Nervous Cardiovascular Page 3 of 5 Medical History: Your Name________________________ Check the box if you have ever been diagnosed with: No Known Medical Problems Gastrointestinal __GERD or Reflux __Barrett's Esophagus __Irritable Bowel Syndrome __Colorectal Disease/Cancer __Gall Bladder Problems __Ulcerative Colitis __Crohn's Disease Last Sigmoid Exam _______________ Last Colonoscopy _______________ Hematologic/Lymphatic __Jaundice/Hepatitis __Other Liver Disorder Respiratory __Lung Disorder (Asthma, Bronchitis, Emphysema) HEENT __Glaucoma/Cataracts __Asthma/Hives __Sleep Apnea Cardiovascular __Heart Disease/Heart condition __Heart Attack/Heart Failure __Rheumatic Fever/Angina __Rapid or Irregular Heart Beat __Abnormal Cardiogram (EKG) __Stroke/Hypertension __Anemia/Blood Problems __Blood Transfusion #_______ Reaction Yes No __Mitral Valve Prolapse GU __Kidney/Bladder Problem __Breast/Prostate Problem Musculoskeletal __Arthritis/Chronic Pain Musculoskeletal __Arthritis/Paralysis __Multiple Sclerosis/Muscular Dystrophy Neurological/Psychological __Nervous Disorder __Seizure Disorder __Depression __Anxiety Endocrine __Thyroid Problem __Diabetes __Eczema/Psoriasis __Birth Defect/Inherited Disease Integumentary/Infectious __Chicken Pox __Measles/Mumps/Rubella __MRSA/VRE/C-Diff __AIDS/HIV __Venereal Disease/Herpes Lifestyle Factors Caffeine and Fluids How many do you drink a day? Cups of Coffee Cups of Tea Cans of Cola Ounces of Water Tobacco Do you smoke or use tobacco products? Yes Never Packs/day___________ # of Years____________ Type: Cigarettes Passive Cigars Quit (Date_______) Pipe Chew Snuff Alcohol and Drugs Do you drink alcohol? Includes beer, wine, distilled spirits/liquor Yes If Yes, how many drinks do you have in a typical: day ______ Glasses of wine Cans of beer Shots of liquor Do you use any "street" dugs? Cocaine, marijuana, methamphetamines Page 4 of 5 No week ______ Yes No month _______ ? Times per week Demographics Your Name Date of Birth: ____________________ Age_______________ Please list any other physicians to whom you would like Copies of information sent: Address: Name: Address: Home Phone: ( Cell Phone: ( Work Phone: ( ) ) ) - Reason for seeing: Lifetime Occupation: Name: Retired: Yes No Address: Employer: Reason for seeing: How did you hear about Pezzone Gastroenterology Associates? Name: Family/Friend Yellow Pages Television Address: Newspaper Internet Marital Status: Single Married Widowed Reason for seeing Name: Name of Spouse: Address: Practices: Are there any religious, ethnic or cultural practices that need Reason for seeing to be part of your care? Yes Contacts: NO Please list a person, who does not have the same phone Number as you, to call if we are unable to reach you. Living Arrangements: Alone Spouse Significant Other Name: Address: Supervised Living Other: Services in your Home: None Aide Nurse Home Phone: ( ) - Work Phone: ( ) - Meals on Wheels Home Care Agency Name: Relationship: Your Pharmacy Name: Emergency Contact: Please list a person you would like us to contact in case of Phone: ( Address: ) - Emergency. Name: Home Phone: ( ) - Work Phone: ( ) - Relationship: Page 5 of 5 Thank You
