Download WACO GASTROENTEROLOGY ASSOCIATES—PATIENT HEALTH

WACO GASTROENTEROLOGY ASSOCIATES—PATIENT HEALTH HISTORY, PART 1
Date: _____________
Name: ____________________________________________
Date of Birth: ________________
Current Medications (include any over the counter medicines, vitamins, supplements, & diet pills)
Name
Dose/Strength
When taken (daily, as needed, etc.)
_______________________________
____________________
_________________________
_______________________________
____________________
_________________________
_______________________________
____________________
_________________________
_______________________________
____________________
_________________________
_______________________________
____________________
_________________________
_______________________________
____________________
_________________________
_______________________________
____________________
_________________________
_______________________________
____________________
_________________________
_______________________________
____________________
_________________________
_______________________________
____________________
_________________________
DRUG ALLERGIES: ______________________________________________________________
Pharmacy Preference: _________________________ Location: _________________ Phone #: __________________
Past Surgeries / Date
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
Have you had a COLONOSCOPY previously?
Have you had an EGD (upper scope) previously?
□ NO
□ NO
__________________________
__________________________
__________________________
□ Yes (When? Where?) _________________________
□ Yes (When? Where?) _________________________
CURRENT WEIGHT: _______________ HEIGHT: ______________ (Staff use, BMI: _____________ )
FAMILY HISTORY--Mark box for any problems that run in your family and tell us what relative
(circle M=mother, F=father, B=brother, S=sister)
□ Colon polyps (M F B S)
□ Blood disorders (M F B S) □ Other diseases (M F B S)
□ Cancer (M F B S)
□ Gastric polyps (M F B S)
□ Pancrea44s (M F B S)
Type: ______________
Type: ______________
□ Liver disease (M F B S)
□ Ulcers (M F B S)
SOCIAL HISTORY
Have you ever smoked? □ Yes □ No
Do you currently smoke? □ Yes □ No
If yes, how number of packs per day? __________
Have you ever used alcohol? □ Yes □ No
Do you currently use alcohol? □ Yes □ No
If yes, how much? □ Daily □ Weekly □ Monthly □ Other: _________
Have you ever used recreational drugs? □ Yes □ No Do you currently use? □ Yes □ No
COMMENTS
Revised 11-4-2015
Info Charted by/Date: ____________________
WACO GASTROENTEROLOGY ASSOCIATES—PATIENT HEALTH HISTORY, PART 2
Date: _____________
Name: ____________________________________________
Date of Birth: ________________
REVIEW OF SYSTEMS—Please mark NO or YES for each item if you have the problem.
NO/ YES
NO/ YES
NO/ YES
NO/ YES
Last visit to cardiologist/results
□ □ Renal insufficiency
□ □ Chemicals in workplace
Constitutional
□ □ Chills
of visit: ___________________ Endocrine
□ □ Food allergies
□ □ Fever
□ □ Immunosuppression
___________________________ □ □ Cold intolerance
□ □ Seasonal allergies
□ □ Malaise/Fatigue
□ □ Heart attack
□ □ Excessive thirst
Reproductive
□ □ Weight Loss
If yes, when? ______________
□ □ Heat intolerance
Head/Eyes/ENT
□ □ Heart valve disease
□ □ Diabetes
Males Only:
□ □ Double vision
□ □ High blood pressure
□ □ Thyroid disease
□ □ Penile discharge
□ □ Ear infections
□ □ Internal defibrillator
Neurological
□ □ Sexual dysfunction
□ □ Eye pain
□ □ Pacemaker
□ □ Dizziness
Females Only:
□ □ Nasal congestion
□ □ Breast lumps
□ □ Peripheral vascular disease □ □ Headache
□ □ Sinus infection
Gastrointestinal
□ □ Numbness
□ □ Breast pain
□ □ Sore throat
□ □ Abdominal pain
□ □ Tremors
□ □ Vaginal discharge
Respiratory
□ □ Change in bowel habits
□ □ Vertigo
□ □ Hysterectomy
□ □ Shortness of breath
□ □ Constipation
□ □ Accident/head injury
□ □ Menopause
□ □ Frequent cough
□ □ Diarrhea
□ □ Alzheimer’s disease
Last Menstrual Cycle: __________
□ □ Painful breathing
□ □ Trouble swallowing
□ □ Amputation
□ □ Tubal ligation
Fall Risk Assessment
□ □ Wheezing
□ □ Heartburn
□ □ Dementia
□ □ Falls, when? _________
□ □ Asthma
□ □ Vomiting blood
□ □ Multiple sclerosis
If yes, last attack ____________ □ □ Rectal bleeding
□ □ Neuromuscular disease
□ □ Hip/knee replacement
□ □ Ever hospitalized for
□ □ Loss of appetite
□ □ Paralysis
in the last six months?
attack? When? _____________ □ □ Blood in stool
□ □ Parkinson’s disease
□ □ Unsteady gait
□ □ Bronchitis
□ □ Nausea
□ □ Seizures
□ □ Use of assistive device
□ □ Reflux
(Type: ____________)
□ □ Emphysema/COPD
□ □ Stroke
□ □ Vomiting
General
□ □ Home use of oxygen
If yes, when ______________
□ □ Barretts
Any residual/weakness ______ □ □ Allergic to eggs
□ □ Pneumonia
□ □ Cirrhosis
□ □ Prior airway difficulties
Psychiatric
□ □ Anemia
□ □ Colitis
□ □ Anxiety
□ □ Anesthesia
□ □ Productive cough
□ □ Colon polyps
□ □ Recent URI
□ □ Depression
complications in past?
□ □ Crohns
□ □ Increased stress
□ □ Auto immune cancer
□ □ Sleep Apnea
□ □ Diverticulosis
□ □ If yes, CPAP?
□ □ Bipolar
□ □ Cancer
□ □ Esophageal stricture
□ □ Tuberculosis
□ □ Schizophrenia
□ □ Chemotherapy
□ □ Hemorrhoids
Cardiovascular
□ □ Other psych disorder
□ □ Difficult intubation start
□ □ Hepatitis
□ □ Chest pain If yes,
Skin
(breathing tube)
Frequency: _________________ □ □ Hiatal hernia
□ □ Contact allergy
□ □ Difficult IV start
Duration: __________________ □ □ Indigestion
□ □ Hives
□ □ Do you take antibiotics
Last occurrence: ____________ □ □ Irritable Bowel
□ □ Itching of skin
prior to dental work?
Caused by: _________________ □ □ Peptic ulcer disease
□ □ Rash
□ □ HIV/AIDS
Occurs at rest? _____________ □ □ Ulcers
Musculoskeletal
□ □ Infectious disease:
What makes it go away? ______ □ □ Unexplained weight loss
□ □ Back pain
Type: _______________
_________________________ Genitourinary
□ □ Muscle pain
□ □ Lupus
□ □ Swelling in hands/feet
□ □ Burning with urination
□ □ Joint Pain
□ □ Missing, chipped/loose
□ □ Palpitations/irregular beat □ □ Blood in urine
□ □ Artificial joint/prosthetic
teeth or dentures?
□ □ Cardiac stents
□ □ Urinary frequency
□ □ Restless leg syndrome
□ □ Recent fever or cold-like
If yes, when? ______________
□ □ Urinary incontinence
Hematologic
symptoms
Other intervention? _________ □ □ Urinary retention
□ □ Easy bleeding
□ □ Recent illness, infection
□ □ Congestive heart failure □ □ Dialysis
□ □ Bleeding disorder
or exposure
If yes, last episode ___________ □ □ Kidney disease
□ □ Easy bruising
□ □ Take prescription diet pills
EF % ______________________ □ □ Kidney stones
□ □ Swollen lymph nodes
Revised 11-4-2015
Info Charted by/Date: ____________________