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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: ____________________