Shenandoah Valley Gastroenterology Center PLLC
Please bring this completed form with you to your appointment.
Appointment date: ______________ Arrival Time: ____________
Name (first, MI, Last)
Date of Birth:
PCP:
How did you hear about us?
Pharmacy name location and phone number:
_______Male ______Female
Referring MD:
Reason for your visit and problems:
Current and recent gastrointestinal problems:
(Circle YES or NO for each)
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
YES or NO
1/5
Nausea
Vomiting: If yes, with or without blood?
Bloating
Belching
Acid reflux or heartburn
Difficulty swallowing
Barrett’s esophagus
Hiatal hernia
Ulcers
H. pylori infection
Decrease appetite or early satiety
Abdominal pain
Changes in bowel habits
Diarrhea
Constipation
Blood in the stool
Black tarry stools
Hemorrhoids
Rectal pain
Colitis
Crohn’s or Ulcerative colitis
Celiac sprue
Colon polyps
Colon cancer
Gallbladder problems
Liver problems
Pancreatic problems
Leakage of stool
Rectal Itching
Dairy intolerance
Patient Initial: _______
Prior Gastrointestinal procedures or imaging:
YES
Bring the official report if possible.
/ Date (M/Y)/ Place of Procedure / Indications or Findings
Colonoscopy
Upper endoscopy
Sigmoidoscopy
Capsule endoscopy
Upper GI series
Small bowel series
Barium enema
ERCP
Endoscopic ultrasound
Abdominal CT scan
Abdominal MRI or MRCP
Abdominal ultrasound
HIDA scan
Gastric emptying study
Other:
Your Past Medical History:
□ Atrial fibrillation
□ Heart attack
□ Heart failure
□ Heart Valve replacement
□ Pacemaker/defibrillator
□ High blood pressure
□ Kidney disease
□ Renal Dialysis
□ Osteoporosis
□ Diabetes I or II
□ Asthma
□ Sleep Apnea
□ Home oxygen
□ COPD
□ Hyperthyroidism
□ Hypothyroidism
□ Any Cancer
□ HIV / AIDS
□ Anemia
□ Blood Transfusions
□ Stroke or CVA
□ Seizures
□ Alcoholism
□ Tobacco use
□ Depression
□ Arthritis
□ Pancreatitis
□ Barrett’s esophagus
□ Colon polyps or cancer
□ Diverticulosis
□ Gallstones
□ Gastric/duodenal ulcers
□ H. pylori
□ C. Difficile
□ Reflux/GERD
□ Crohn’s /UC
Are you pregnant? YES or NO or Uncertain
Date of your last menstrual period? (M/D/Y)
Seasonal allergies? YES or NO
Other:
Past Surgical History:










2/5
No surgical history
Angioplasty
Heart surgery
Lung surgery
Pancreatic
Vaginal/ Bladder
Ileostomy/colostomy
Liver surgery
Laparoscopy
Vascular surgeries
*Please Provide Month(M) and Year(Y) of the surgery*
M/Y:
 Abdominal
M/Y:
M/Y:
 Cholecystectomy
M/Y:
M/Y:
 Appendectomy
M/Y:
M/Y:
 Hernia repair
M/Y:
M/Y:
 Hysterectomy
M/Y:
M/Y:
 Gastric band
M/Y:
M/Y:
 Gastric bypass
M/Y:
M/Y:
 Colon resection
M/Y:
M/Y
 Other:
M/Y
Patient Initial: _______
Family History:
(Circle YES or NO for each)
 Unknown Family history
Colon Cancer
YES
NO
Relation(paternal or maternal):
Colon Polyps
YES
NO
Relation(paternal or maternal):
Crohn’s or Ulcerative Colitis
YES
NO
Relation(paternal or maternal):
Liver Disease
YES
NO
Relation(paternal or maternal):
Gallbladder Disease
YES
NO
Relation(paternal or maternal):
Celiac Disease/ Gluten
Intolerance
Heart disease
YES
NO
Relation(paternal or maternal):
YES
NO
Relation(paternal or maternal):
Diabetes
YES
NO
Relation(paternal or maternal):
Any other cancer
YES
NO
Type and Relation:
Social History:
Current occupation / Employer:
Marital status (circle one): Single, Married, Divorced, Separated, Partnered, Widowed
Alcohol Use
YES or NO
 Beer
Drinks per week? ____________
 wine
Drinks per Month? ___________
 liquor
Last time you had a
drink? ____________________
3/5
Recovering alcoholic
YES or NO
When did you quit?
Illicit drugs
YES or NO
When was the last
time you used drugs
and what type?
Have you ever used a needle for drug
administration?
YES or NO
Tobacco use
YES or NO
For how long?
Tattoos
YES or NO
How many packs per
day?
Body area?
Body Piercing
YES or NO
Body area?
Diet products
consumption
Caffeine
YES or NO
Type?
Quantity?
YES or NO
Type?
Quantity?
Patient Initial: _______
Do you have any of the following symptoms?
(Mark all that apply)
 GENERAL
 Dentures
 Frequent UTIs
 Memory loss
 Weight loss
_____lbs
 Weight gain
_____lbs
 Fever/ Chills
 Nose bleeds
 Kidney stones
 Tingling
 Hearing loss
 Pregnant
 Numbness
 CARDIOVASCULAR
 MUSCULOSKELETAL
 Stroke
 Weakness
 Chest pain
 Neck pain
 Seizures
 Fatigue
 Chest pressure
 Back pain
 PSYCHIATRIC
 Night sweats
 Abnormal swelling
of the legs
 Irregular heart
beats
 Lightheadedness
 Joint pains
 Anxiety
 Stiff joints
 Depression
 Arthritis
 Scleroderma
 Vision loss
 Passing
out/syncope
 RESPIRATORY
 Past evaluation and
treatment
 ENDOCRINE
 Lupus(SLE)
 Excessive Thirst
 Use of glasses
 Shortness of breath
 SKIN
 Excessive Urination
 Glaucoma
 Wheezing
 Yellow skin
 Intolerance to cold
 ENT
 Asthma or COPD
 Rashes
 Intolerance to Heat
 Mouth ulcers
 Trouble breathing
 Psoriasis
 Teeth decay
 Cough
 Dermatitis
 HEMATOLOGY/
LYMPHATIC
 Bleeding problems
 Sinus problems
 GENITOURINARY
 Itching
 Transfusions
 Sore throat
 Blood in urine
 NEUROLOGICAL
 Miscarriages
 Hoarseness
 Burning urinating
 Headaches
 Large lymph nodes
 Insomnia
 EYES
 Yellow eyes
4/5
Patient Initial: _______
Please list ALL MEDICATIONS and ALLERGIES below
or bring a list with you.
Allergies:
Do you have any known drug allergies?
Any adverse reaction to sedation or anesthesia?
Are you allergic to latex?
Are you allergic to eggs or soy?
YES
YES
YES
YES
Name of Medication Allergies
or
or
or
or
NO
NO
NO
NO
Reaction
MEDICATIONS LIST:
(Including over the counter medications and natural remedies) Please list all
medications or bring a list with you.
Do you use any of the following medications?
YES Medication name
Blood Thinners: Coumadin
warfarin, Plavix, Xarelto.
Oral steroids
Baby aspirin
Regular aspirin, Aleve or Excedrin
Ibuprofen(Advil/Motrin/
Naproxen)
Laxatives
Iron
Calcium
Multivitamins or natural remedies
Other non prescription drugs
Medication List
Strength and dose
How many time a day
Strength and dose
Times per day
The information provided above has been accurately completed to the best of my knowledge:
5/5
____________________________________________________________________
Patient Signature
________________________________
Date