LONDONDERRY GASTROENTEROLOGY ASSOCIATES
MEDICAL HISTORY FORM
Phone: (603) 818-4712
NAME:
TODAY’S DATE:
ADDRESS:
DATE OF BIRTH:
PHONE NUMBER_
HEIGHT ____________ WEIGHT____________
REASON FOR YOUR VISIT:_
Allergies
O None
O Aspirin - reaction:
O Codeine – reaction:
O Demerol – reaction:
O Eggs - reaction:
O IV contrast or iodine - reaction:
O Latex – reaction
O Penicillin – reaction
O
O
O
O
O
Sulfa - reaction:
Valium - reaction:
Propofol - reaction:
Versed - reaction:
Other - reaction:
O
Abdominal aortic aneurysm
O
COPD on oxygen (emphysema –I use oxygen)
O
Alcoholism
O
COPD not on oxygen (emphysema –I don’t use oxygen)
O
Alzheimer’s
O
O
Anemia due to iron deficiency (low blood count due to
low iron)
Coronary artery disease with myocardial infarction (heart
blockages and heart attack)
O
Anemia due to B12 deficiency (low blood count due to
low B12)
Coronary artery disease without myocardial infarction
(Heart blockages without heart attack)
O
Crohn’s colitis (Crohn’s of the colon)
O
Crohn’s ileitis (Crohn’s of the small intestine)
O
Crohn’s ileocolitis (Crohn’s of the small and large
intestine)
O
Deep vein thrombosis (blood clot)
O
Degenerative joint disease
O
Depression
O
Diabetes mellitus Type I (I must take insulin, started in
childhood)
O
O
Anemia of chronic disease (low blood count due to
sickness)
O
Anemia, nonspecific (low blood count of uncertain
cause)
O
Anxiety
O
Ascites (fluid in abdomen)
O
Asthma
O
Atrial fibrillation (heart rhythm problem)
O
Barrett’s esophagus
O
Diabetes mellitus Type II (adult onset diabetes)
O
Breast cancer
O
Dilated cardiomyopathy (very weak heart muscle)
O
Cardiac valvular disease (heart valve problem)
O
Diverticulitis (colon pockets got infected)
O
Cerebral artery aneurysm
O
Diverticulosis (colon pockets –no infection)
O
Chronic anticoagulation (Coumadin,Plavix etc.)
O
Drug abuse/dependency
O
Chronic pain syndrome (for which I see the pain clinic)
O
Elevated liver enzymes
O
Cirrhosis of liver
O
O
Colon cancer
Esophageal varices with bleeding (veins in the
esophagus which bled)
O
Colon polyps
O
Esophageal varices without bleeding (veins in the
esophagus which haven’t bled)
O
Congestive heart failure (fluid in the lungs)
O
Fatty liver
Name:
Page 2 of 4
O
Osteoporosis (severe low bone density)
O
Pancreatitis, acute (occurred once)
O
Fibromyalgia
O
Pancreatitis, chronic (occurred several times)
O
Frequent UTI’s
O
Parkinson’s disease
O
Gastric varices (veins inside the stomach)
O
Pneumonia
O
GERD (reflux/heartburn)
O
PPD positive (positive skin test for TB)
O
Glaucoma
O
Prostate cancer
O
Gout
O
Renal failure (kidney failure on dialysis)
O
Heart murmur
O
Renal failure(kidney failure, not on dialysis)
O
Hepatic encephalopathy (confusion due to liver disease)
O
Renal transplantation (kidney transplant)
O
Hepatitis A
O
Rheumatic fever
O
Hepatitis B
O
Rheumatoid arthritis
O
Hepatitis C
O
Seizure disorder
O
HIV/AIDS
O
Sick sinus syndrome
O
Hodgkin’s disease
O
Skin cancer, melanoma
O
Hypercholesterolemia (high cholesterol)
O
Skin cancer, non-melanoma
O
Hypertension (high blood pressure)
O
O
Hyperthyroid (high thyroid-overactive)
Spontaneous bacterial peritonitis (infected fluid in
abdomen due to liver problems)
O
Hypertriglyceridemia (high triglycerides)
O
Stroke
O
Hypothyroid (low thyroid-underactive)
O
Supraventricular tachycardia
O
Irritable bowel syndrome
O
Thoracic aneurysm
O
Liver transplantation
O
Transient ischemic attack (mini stroke)
O
Name
O
Tuberculosis
O
Lymphoma
O
Ulcerative colitis
O
Migraines
O
Ulcer, duodenal
O
Nephrolithiasis (kidney stones)
O
Ulcer, gastric
O
Obesity
O
Ventricular tachycardia
O
Osteopenia (mild low bone density)
O
Other
Name:
Page 3 of 4
Marital status
SOCIAL HISTORY
Recreational drug use
O Single
O Separated
O Married
O I have never used recreational drugs
O Divorced
O Widowed
O Other
O I have used recreational drugs in the past
O I currently use recreational drugs
Number of children
O1
O5
O2 O3 O4
O 6+ O None
Alcohol
O Never
O More than 2 days/week
O Rarely
O Less than 2 days/week
O Daily
O I quit using alcohol
O I have been treated for substance abuse
Tobacco
O I use tobacco products
O I have never used tobacco products
O I quit using tobacco products/year
O Cigarettes/cigars
Occupation
Patient Occupation_
O Veteran
O Retired
O Prior abuse
FAMILY HISTORY
FATHER
MOTHER
CHILD(REN)
BROTHER OR SISTER
GRANDPARENTS
Deceased
O
O
O
O
O
Healthy
O
O
O
O
O
Breast Cancer
O
O
O
O
O
Alcoholism
O
O
O
O
O
Bleeding Tendency
O
O
O
O
O
Cancer
What kind?
Age at diagnosis
O
O
O
O
O
Colon Polyps
Age at diagnosis_
O
O
O
O
O
Diabetes
O
O
O
O
O
Heart Attack
O
O
O
O
O
Liver Disease
O
O
O
O
O
Stomach Cancer
O
O
O
O
O
Other
O
O
O
O
O
Name_
REVIEW OF SYSTEMS
Page 4 of 4
Gastrointestinal:
O None
O Abdominal Pain
O Black tarry stools
O Bloating
O Change in bowel habits
O
O
O
O
Constipation
Diarrhea
Difficulty swallowing
Heartburn
Genitourinary
O None
O Change in urinary frequency
O Frequent urinary infections
O Dryness
O Rashes
Cardiovascular:
O NONE
O Ankle Swelling
O Chest Pain
O Palpitations
O Hives
O Other_
O Shortness of breath when lying flat
O Shortness of breath with exertion
O Excessive thirst
O Hair loss
O Fatigue
Eyes
O None
O Visual decline
Hematologic
O None
O Easy bruising
Ears, Nose, and Throat
O None
O Hearing loss
Musculoskeletal
O None
O Joint Pain
Revised 7/9/2013
O Other
O Weight gain
O Depression
O Suicidal thoughts
Immunologic
O None
O Other
O Other
Psychiatric
O None
O Anxiety/panic
Respiratory
O None
O Cough
O Cough up blood
Rectal bleeding
Rectal urgency
Soiling stool
Vomiting
O Numbness in extremities
Endocrine
O None
O Cold intolerance
Constitutional:
O None
O
O
O
O
O Kidney disease/failure
O Other
Skin
O None
O Itching
Neurological
O None
O Dizziness
O Headaches
O Milk/dairy intolerance
O Mucous in stool
O Nausea
O Pain with bowel movement
O Other
O Nose bleeds
O Sore throat
O Joint swelling
O Weight loss
O Other
O Other
O Oth er
O Prolonged bleeding
O Other
O Other
O Muscle pain
O Other
O Shortness of breath
O Wheezing
O Other_
O Allergies (environmental)
O Recurrent hives
O Other