Patient History Left colName Email Age Height Weight Please state the main reason(s) you have an appointment with our office.GI Review of Systems Have you recently had any of the following symptoms?1. Have you had recent pain in your upper abdomen? Yes No 2. Do you have pain in the upper abdomen that you can locate with one finger? Yes No 3. Does your pain spread throughout your upper abdomen? Yes No 4. Do you have difficulty swallowing food or liquids? Yes No 5. Do you have heartburn? (burning in your chest or throat) Yes No 6. Do you have chest pressure or tightness? Yes No 7. Do you notice any of the following tastes in your mouth? metallic bitter acid sour none 8. Do you often have a hoarse voice? Yes No 9. Do you often have to clear your throat of mucus? Yes No 10. Do you often cough? Yes No 11. Do you have difficulty swallowing ... liquids solid food tablets No 12. Does it hurt to swallow? Yes No 13. Do you feel bloated ofter a meal? Yes No 14. Do you feel bloated in your upper abdomen? Yes No 15. Do you have difficulty completing your meals? Yes No 16. Do you feel as if you might vomit after a meal? Yes No 17. Do you vomit after a meal? Yes No 18. Have you vomited blood? Yes No 19. Do you feel sick at other times of the day? Yes No 20. Do you get pain in your upper abdomen after eating fatty or greasy foods? Yes No 21. Do you belch more than normal? Yes No 22. Does abdominal pain wake you up at night? Yes No 23. Is the pain in your abdomen relieved by eating? Yes No 24. Is the pain relieved by taking over-the-counter antacids? Yes No 25. Do you have pain in your lower abdomen? Yes No 26. Is this pain relieved by bowel movements or passing gas? Yes No 27. Have you had a recent change in the frequent, shape or consistency of your bowel movements? Yes No 28. Have you had recurrent diarrhea, or do you have continuous diarrhea? Yes No 29. Have you recently had problems with an episode of constipation, or do you have frequent or chronic constipation? Yes No 30. Have you recently had an urgent need to have a bowel movement that makes you rush to the toilet? Yes No 31. Do you sometimes not make it to the toilet in time? Yes No 32. Do you have to strain while having a bowel movement? Yes No 33. Do you have rectal pain in association with a bowel movement, or at any other time such as in the middle of the night? Yes No 34. Have you felt unable to complete your bowel movement? Yes No 35. Do you see blood? on the toilet paper on the surface of the stool mixed in with the stool in the water of the toilet bowl No 36. Do you have black tarry stools? Yes No 37. Do you see mucus in your stool? Yes No Gastrointestinal History Check if you currently have OR have had any of the following: UIcerative colitis Crohn's colitis Crohn's enteritis (small intestine) Crohn's ileocolitis (small intestinal and colon) Gallstones Gallbladder disease Fatty liver disease Hepatitis Cirrhosis of the liver Liver cysts or tumor Pancreatic problems Colon polyps H. pylory stomach infection Esophageal problems Peptic ulcer Acid reflux Gastrointestinal bleeding Anemia Blood transfusion - when? Cancer Colon Rectal Liver Pancreas Stomach Esophageal Anal Other Alcohol-related illness Anorexia nervosa Bulimia Lactose intolerance Celiac disease Irritable bowel syndrome Hemochromatosis Hemorrhoids Anal fissure/fistula Enema use Diverticulosis Diverticulitis Chronic constipation Chronic diarrhea Colon polyps NONE Check if you have undergone Colonoscopy Upper endoscopy Sigmoidoscopy None If not performed by Dr. Marcus:a) Who performed this procedure? b) Where was the procedure performed? c) When was it performed? d) What was found? General Medical Conditions Check if you currently have OR have had any of the following: AIDS Anxiety disorders Arthritis Asthma Atrial fibrillation or other arrhythmias Bleeding disorders Blood clotting disorders Chicken pox Chronic bronchitis Congestive heart failure COPD Dementia Depression Diabetes (non-insulin-dependent) Diabetes (insulin-dependent) Drug abuse Electrolyte imbalance Emphysema Epilepsy Goiter Gout Heart attack Heart disease Heart murmur Herpes High cholesterol HIV positive Hypertension Kidney disease Kidney stones Migraine headaches Multiple sclerosis Osteoporosis Pacemaker Pneumonia Prostate problems Psychiatric care Rheumatic fever Sleep apnea Seizure disorders Stroke Tubercoulosis Positive PPD TB test Problems with anesthesia Valvular heart disease Multiple drug allergies Severe allergic reactions Cancer Breast Thyroid Prostate Skin Other NONE Left colCheck any surgeries you have had and state the approximate year. Appendix Breast CABG Cataract Cesarean delivery Colon/Bowel D&C Esophagus Gallbladder Hemorrhoids Hernia Hysterectomy Orthopedic Ovarian Pancreas Prostate Stent placement Stomach Tonsils Tubal ligation Other Right colAppendix Year Breast Year CABG Year Cataract Year Cesarean delivery Colon/Bowel Year D&C Year Esophagus Year Gallbladder Year Hemorrhoids Year Hernia Year Hysterectomy Year Orthopedic Year Ovarian Year Pancreas Year Prostate Year Stent Placement Year Stomach Year Tonsils Year Tubal ligation Year Other Year Right col endList any other hospitalizations, illnesses or possible conditions:Medication List None Have you taken any antibiotics in the past 30 days? Yes No Which drug? Do you take:Blood thinners? Yes No Aspirin? Yes No Fish oil? Yes No Vitamins? Yes No Herbals? Yes No Name of medicationDoseHow often Do you routinely take over-thecounter medications? Yes No Medication Allergies Are you allergic to:Penicillins? Yes No Sulfa drugs? Yes No Other medications? Yes No Please list: Personal HabitsTOBACCO:Have you ever smoked cigarettes regularly? Yes No If yes, what age did you start? What age did you stop? Number of cigarettes per day? Number of years you smoked? ALCOHOL:Do you drink every day? Yes No How many drinks per week? Have you ever felt badly about something that happened because of you drinking? Yes No RECREATIONAL DRUGS:Do you use or have you used recreational drugs? Yes No Which ones? Do you have any dietary restrictions? Yes No Please check all that are appropriate Vegetarian Vegan Lactose intolerance Diet free of red meat Gluten Other Sexual History - RelationsDo you prefer Man Women Both Abstinent Have you had relations with someone who is sexually promiscuous or who has HIV/AIDS? Yes No Social HistoryWhere were you born? Relationship StatusSMPDWDo you have any children? Please list your current or past professions: Family HistoryWhere was your mother born? Age if living or age of death Where was your father born? Age if living or age of death Please indicate who in your family may have had the following? M = Mother F = Father S = Sibling GP = Grandparent C = ChildCancerCeliac disease M F S GP C Breast M F S GP C Hypertension M F S GP C Colitis M F S GP C Esophageal M F S GP C Stroke M F S GP C Crohn's disease M F S GP C Stomach M F S GP C Heart disease M F S GP C Colon polyps M F S GP C Pancreas M F S GP C Diabetes M F S GP C Liver disease M F S GP C Liver M F S GP C Arthritis M F S GP C Hepatitis B or C M F S GP C Colon M F S GP C Osteoporosis M F S GP C Peptic ulcer disease M F S GP C Other Anemia M F S GP C Alcoholism M F S GP C Drug addiction M F S GP C Have any of your blood relatives had colon or rectal cancer? Yes No Who? Age the cancer was diagnosed Have any of your blood relatives had colon polyps? Yes No Who? Have any of your blood relatives had gastric or esophageal cancer? Yes No Who? Review of SymptomsGeneral: Loss of appetite Recent weight loss or gain Fevers Weakness OtherSkin: Itching Rash Other skin disorderEars: Infections Loss of hearing Eyes: Redness Cataracts Glasses OtherNose: Nosebleeds Chronic postnasal drip Hay fever OtherMouth and Throat: Bleeding gums Sore throats Hoarseness Mouth sores Chest: Cough Sputum Breathlessness Coughing blood Wheezing Heart: Chest pain Palpitations Shortness of breath Breathlessness when lying down Waking up breathless from sleep Ankle swelling OtherUrinary: Increased frequency Blood in urine Pain with urination Urinate more than 2 times at night OtherMusculoskeletal: Joint pain Joint swelling Muscle weakness or pain OtherEndocrine: Excess thirst Heat or cold intolerance OtherNeurologic: Headaches Loss of consciousness Seizures Persistent tingling Numbness Paralysis OtherHematologic: Easy bruising Excessive bleeding if cut or after dental extractions Female (dates):Last normal menstrual period Last mammogram Last Pap smear Last DEXA bone scan
