Columbia Office (near Costco):
8186 Lark Brown Road
Suite 104
Elkridge, MD 21075
The Crain Mayo Medical Building:
1720 S Crain Highway
Suite 102
Glen Burnie, MD 21061
The private practice of Mukul Khandelwal, MD & Mahmood Solaiman, MD, FACG
Phone: (410) 590-8920
Fax: (410) 553-2345
www.MDgastro.net
The following information is very important to your health. Please take time to fully and completely fill
out this important information.
NAME: ______________________________
TODAY'S DATE: _________________
DATE OF BIRTH: __________________ REFERRED BY________________________
REASON FOR VISIT______________________________________________________
Past or Present Medical Problems:
O None
O Colon Cancer
O Diverticulitis
O Diverticulosis OAnemia
O Crohn’s Dis.
O Ulcerative Col. O Irritable Bowel O Celiac Sprue
O Pancreatitis
O Barrett’s Esop. O GERD
O Esop. Cancer
O Ulcer
O Gallstones
O Hepatitis
O Liver Disease
O Stroke
O Osteoporosis
O Lupus
O Arthritis
O Diabetes
O Heart Disease O Atrial Fib.
O Irreg. heartbeat
O Hypertension
O Glaucoma
O Gout
O High Cholesterol O Sleep Apnea
O Breast Cancer
O Lung Cancer
O Asthma
O Emphysema/COPD
O Anxiety
O Prostate Cancer O Kidney Disease O Kidney Stones O Psychiatric Dis. O Depression
O Seizure Disorder
O Gyn Cancer
O Bleeding Disorder Other__________________________________________________________
Surgeries/Hospitalization/Procedures:
O None
O Colon Surgery O Gallbladder Surgery
O Prostate Surgery O Colonoscopy O EGD/endoscopy
O Colostomy
O Hysterectomy O C-Section
O Joint Surgery
O Heart Surgery O Heart Stent
O Pacemaker
O Appendectomy O Blood Transfusions
Other_______________________________________________
O Hernia Surgery
O ERCP
O Hiatal Hernia Repair
O Defibrillator (AICD)
O Gastric BypassSurgery
O Orthopedic Surgery
Social History - Marital Status
Recreational Drugs O None
Children ONone How many_____
O I have used IV drugs in the past.
O Single O Separated O Married
O I currently use recreational drugs.
O Divorced O Widowed O Partnered
O I have been treated for substance abuse
Social History -Alcohol
Social History - Tobacco
O Never O More than 2 days/week.
O I use tobacco products.
O Rarely O Less than 2 days/week.
O I have never used tobacco products.
O Daily O I quit using alcohol
O I quit using tobacco products.
Social History - Occupation _________________________ O Retired
Review of Systems
Gastrointestinal
O None
O Blood in Stool
O Heartburn
O Loss of Appetite
O Abdominal pain O Change in Bowel Habits O Hemorrhoids
O Milk Intolerance
O Belching
O Constipation
O Incontinence
O Nausea
O Black Stools
O Diarrhea
O IBS
O Bloating
O Gas
O Jaundice
O Vomiting
O Painful Bowel Movement
O Other________________
Genitourinary
Skin/Integument
O None
O Irregular Menstruation
O None
O Rash
O Blood in Urine
O Pain on Urination
O Itching
O Other__________________
O Dark Urine
O Sexually Transmitted Disease
O Diminished Urine Flow
O Urinary Incontinence
O Frequent Urinary Infections O Other___________________
O Frequent Urination
Columbia Office (near Costco):
8186 Lark Brown Road
Suite 104
Elkridge, MD 21075
The Crain Mayo Medical Building:
1720 S Crain Highway
Suite 102
Glen Burnie, MD 21061
The private practice of Mukul Khandelwal, MD & Mahmood Solaiman, MD, FACG
Phone: (410) 590-8920
Fax: (410) 553-2345
www.MDgastro.net
Cardiovascular
O Angina/Chest Pain O Irregular Heart Beat
O Ankle Swelling
O Other_____________________
Neurological
Endocrine
O None
O Seizures
O None O Excessive Thirst
O Dizziness
O Stroke or Paralysis
O Cold Intolerance
O Headaches
O Other __________________
Constitutional
Psychiatric
O None
O Weight Gain
O None
O Depression
O Fever
O Weight Loss
O Abnormal Sleep O Memory Loss/Confusion
O Night Sweats
O Other _________________
O Chronic Anxiety
Eyes
Hematologic
O None
O Eye Pain
O None
OProlonged Bleeding
O Change in Vision O Other__________________
O Enlarged Glands
O Dry Eyes
Ears, Nose and Throat
Musculoskeletal
O None
O Hoarseness
O None
O Muscle Pain
O Bleeding Gums
O Mouth Sores
O Back Pain
O Chronic Sore Throat
O Nose Bleeds
O Joint Pain
O Dry Mouth
O Other __________________
Respiratory
Immunologic
O None
O Wheezing
O None
O Pneumonia
O Chronic Cough
O Other ______________
O Ear Infections O Other ____
O Shortness of Breath O Flu
FAMILY HISTORY
Colon Cancer
Colon Polyps
Crohn’s Disease
Ulcerative Colitis
Esophageal Cancer O
Gastric Cancer
Pancreatic Cancer
Liver Disease
Gyn Cancer
Breast Cancer
Allergies:
O None
O Aspirin
Father
O
O
O
O
O
O
O
O
O
O
O Demerol/Fentanyl
O Eggs
Mother
O
O
O
O
O
O
O
O
O
O
Child(ren)
O
O
O
O
O
O
O
O
O
Brother/Sister Other
O
O
O
O
O
O
O
O
O
O
O
O IV Contrast or Iodine
O Propofol/Diprivan
O Penicillin
OVersed
List of Medications: Please list on the left margin.
The above is true and correct to the best of my belief.
Patient's Signature:__________________________________________________
Date:___________________
O
O
O
O
O
O
O
O
O
O Sulfa O Latex
O Other________