Patient Information
Binghamton Gastroenterology Associates
Name: ________________________________Today's Date: ________________DOB: ____________ Age:_____
Employer:
Occupation:
How where you referred to our office?
What is the main reason for your visit today?
PATIENT MEDICAL HISTORY Have you had any of the following problems or conditions? Please circle Yes or No
Liver Disease
Y
N
Diabetes
Y
N
Thyroid Disorders
Y
N
Hepatitis
Y
N
Asthma
Y
N
High Blood Pressure
Y
N
Heart Disease
Y
N
Cancer
Y
N
Heart Murmur
Y
N
Heart Attack
Y
N
Arthritis
Y
N
Prostate Problems
Y
N
Angina
Y
N
Seizures
Y
N
Colon/Bowel troubles
Y
N
Eye Disorders
Y
N
Clotting Disorders
Y
N
Kidney Disease
Y
N
Tuberculosis
Y
N
Depression
Y
N
Stomach Ulcers
Y
N
Rectal Trouble
Y
N
Heart Arrhythmia
Y
N
Infectious Disease
Y
N
Emphysema
Y
N
Radiation
Y
N
Sleep Apnea
Y
N
Anxiety
Y
N
Psychiatric Illness
Y
N
Other
Y
N
If yes to any of the above, please explain
SURGICAL HISTORY (Place a check mark next to any of the following surgeries you’ve had)
Heart
Kidney
Breast Biopsy
Tonsils
Uterus/ Ovaries
Mastectomy
Appendix
Hysterectomy
Colon/Intestines
Gallbladder
Stomach/Hernia
Prostate
Cataract
Vascular
Thyroid
Joint Replacement
OTHER HOSPITALIZATIONS/SURGERIES (Please list reasons and year)
FAMILY HISTORY (BLOOD RELATIVES ONLY) Circle Yes or No and specify relationship
Cancer
Y
N
Kidney Disease Y
N
Thyroid Disorders
Y
N
Liver Disease
Y
N
Lung Disease
Y
N
High Blood Pressure Y
N
Pancreatic Disease Y
N
Heart Disease
Y
N
Arthritis
Y
N
Blood Disorders
N
Diabetes
Y
N
Bowel Disorders
Y
N
Anesthesia Reaction Y
N
Y
CONTINUED ON THE BACK
SOCIAL HISTORY:
Marital Status: S M D W
Do you Smoke? ________________ If Yes how much? __________ Would you like information on quitting? Y
Do you drink Alcohol? _____________ If Yes how much? _______ Do you have a Health Care Proxy?
Have you received the Pneumonia Vaccine?
Y
N
Y
N
N
If yes, when
If you are between the ages of 45-65 have you been tested for Hepatitis C?
Y
N
If yes, result
List any Allergies to drugs, environment, food, etc.
REVIEW OF SYSTEMS: Do you have any of the following problems or conditions? Circle Yes or No
Constitutional
Respiratory
Integumentary
Fatigue
Y
N
Frequent Cough
Y
N
Rashes
Y
N
Weight loss
Y
N
Wheezing
Y
N
Sores
Y
N
Weight gain
Y
N
Shortness of Breath
Y
N
Hair Loss
Y
N
Fever
Y
N
Gastrointestinal
Night sweats
Y
N
Abdominal Pain
Y
N
Headaches
Y
N
Appetite Problem
Y
N
Tremors
Y
N
Eyes
Neurological
Blurred vision
Y
N
Nausea/Vomiting
Y
N
Dizzy Spells
Y
N
Double vision
Y
N
Indigestion/Heartburn
Y
N
Numbness/Tingling
Y
N
Pain
Y
N
Change in Bowel Habits
Y
N
Seizures
Y
N
Glasses?
Y
N
Genitourinary
Ear/Nose/Throat/Mouth
Psychological
Urinary Frequency
Y
N
Mood Swings
Y
N
Hearing Loss
Y
N
Painful Urination
Y
N
Depression
Y
N
Nasal/Sinus Problems
Y
N
Nighttime Urination
Y
N
Other
Y
N
Sore/Bleeding Gums
Y
N
Hesitant Stream
Y
N
Endocrine
Dentures?
Y
N
Musculoskeletal
Heat Intolerance
Y
N
Cardiovascular
Leg Pain
Y
N
Cold Intolerance
Y
N
High Blood Pressure
Y
N
Muscle Weakness
Y
N
Excessive Sweating
Y
N
Chest Pain
Y
N
Back Pain
Y
N
Excessive Thirst
Y
N
Leg Swelling
Y
N
Movement Limitation
Y
N
Palpitations
Y
N
Hematologic/Lymphatic
Swollen Glands
Y
N
Spontaneous Bleeding
Y
N
Bruise Easily
Y
N
Blood Clotting
Y
N