Associates in Gastroenterology & Liver Disease
Medical and Family History Form
Please fill in the circles for the appropriate health information
NAME:____________________________________________________ DATE:__________________
BIRTHDATE:______________________AGE:__________ REFERRED BY:___________________
HEIGHT:__________ WEIGHT:__________ PRIMARY CARE DOCTOR:___________________
Ethnicity: ○ Not Hispanic/Latino ○ Hispanic/Latino ○ Declined ○ Unknown Race:_____________
PHARMACY (name, location, phone/fax number):_____________________________________________
REASON FOR YOUR VISIT TO THE OFFICE:
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Heartburn
○ Nausea
Difficulty swallowing ○ Vomiting
Painful swallowing
○ Upper abdominal pain
Regurgitation
○ Lower abdominal pain
Excessive belching
○ Bloating
Chest pain
○ Gas/flatulence
Abnormal liver tests
Personal history of colon polyps/cancer
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Diarrhea
○ Hemoccult + stools
Constipation
○ Anemia
Narrowed stools
○ Decreased appetite
Rectal pain/itching
○ Weight loss
Rectal bleeding
○ Jaundice
Black stools
○ Screening colonoscopy
Abnormal ultrasound or CAT scan
Family history of colon polyps/cancer
○ Other:______________________________________________________________________________
________________________________________________________________
Have you had any of the following done to evaluate for the cause of your symptoms?
○ Laboratory tests or blood work
○ Radiology imaging (x-rays, ultrasounds, CAT scans, MRIs, barium studies)
○ Endoscopies (upper GI scope/EGD, ERCP, colonoscopy)
○ Emergency room visits
**If possible, we would greatly appreciate it if you would please bring any relevant medical records with you or
have them faxed to our office in advance of your visit – Fax (847) 295-1574.
What medications have you tried to treat your symptoms with (non-prescription and prescription)? ________
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ALLERGIES
○ NONE
○ Demerol
○ Iodine dye
○ Morphine
○ Propofol
○ Surgical tape
○ Codeine
○ Fentanyl
○ Latex
○ Penicillin
○ Sulfa
○ Versed
○ Other:____________________________________________________________________________
Any prior difficulties with sedation or anesthesia (nausea/vomiting, high tolerance, other)? ○ Yes
○ No
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Initials__________
MEDICATIONS
Please be certain to include birth control pills, hormones, and ALL non-prescription medications, such as antiinflammatories (i.e. aspirin, advil, motrin, aleve, ibuprofen), acid blockers (i.e. zantac, pepcid, tagamet, prilosec OTC), topical
hemorrhoidal creams (i.e. anusol, preparation H), vitamins, and herbal supplements.
Medication
Dosage
Frequency
PAST MEDICAL ILLNESSES
Gastrointestinal
○ Heartburn/GERD
○ Hiatal hernia
○ Gastritis
○ H. pylori
○ Ulcer
○ Celiac disease
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Gallstones
Pancreatitis
Irritable bowel (IBS)
Spastic colitis
Lactose intolerance
Diverticulosis
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Diverticulitis
Ulcerative colitis
Crohn’s disease
Colon polyps
Colon cancer
Hemorrhoids
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Cardiovascular
○ High blood pressure
○ High cholesterol
○ Angina
○ Heart attack
○ Atrial fibrillation
○ Tachycardia
Pulmonary
○ Sleep apnea
○ Asthma
○ Emphysema (COPD)
○ Pneumonia
○ Pulmonary embolism
○ Sarcoidosis
Neuropsychiatric
○ Stroke
○ TIA (mini-stroke)
○ Multiple sclerosis
○ Seizures
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Hematologic
○ Anemia
○ Blood transfusion
○ Blood clot
○ Hemochromatosis
Migraines
Chronic headaches
Parkinson's disease
Myasthenia gravis
Pt Intake Form/R Drive/Pt Registration Forms/2015-01
○ PVCs
○ Rhythm disorder
○ Heart murmur
Dementia
Depression
Anxiety
Bipolar disorder
○ Hodgkin's disease
○ Lymphoma
Anal fistula
Anal fissure
Stool incontinence
Abnormal liver tests
Fatty liver
Hepatitis ○ Cirrhosis
○ Mitral valve prolapse
○ Rheumatic fever
○ Congestive heart failure
○ Lung cancer
○ Pleurisy
○ Eating disorder
○ ADHD
○ Hormonal mood
disorder
○ Leukemia
○ Myelodysplastic syndrome
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Initials__________
Endocrine
○ Diabetes
○ Hypothyroidism
○ Hyperthyroidism
○ Thyroid nodule
○ Goiter
○ Thyroid cancer
Genitourinary
○ Kidney disease
○ Kidney stones
○ Kidney tumors/cysts
○ Bladder cancer
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Breast
○ Fibrocystic breast changes
Musculoskeletal
○ Osteoarthritis
○ Rheumatoid arthritis
Urinary tract infections
Bladder incontinence
Prostate hypertrophy
Prostate cancer
○ Abnormal Pap smears
○ Cervical cancer
○ Endometriosis
○ Breast cancer
○ Osteoporosis
○ Osteopenia
○ Fibromyalgia
○ Polymyalgia rheumatica
Eyes, Ears, Nose, and Throat
○ Glaucoma
○ Macular degeneration
○ Cataracts
○ Retinal detachment
Dermatologic
○ Eczema
○ Psoriasis
Ovarian cyst(s)
Ovarian cancer
Uterine fibroids
Uterine cancer
○ Pituitary problem
○ Adrenal problem
○ Vitiligo
○ Alopecia
○ Allergic rhinitis
○ Sinusitis
○ Raynaud's syndrome
○ Basal cell skin cancer
○ Lupus
○ Gout
○ Oral thrush
○ Sjogren’s
○ Squamous cell skin cancer
○ Melanoma
Oncologic
○ Any other malignant tumors not previously mentioned:_______________________________________
Infectious Disease
○ Any communicable disease, such as hepatitis, HIV, or sexually transmitted disease?_________________
○ Any other hospitalizations or medical conditions not previously mentioned:_______________________
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PREVIOUS SURGERIES AND PROCEDURES
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Gallbladder
Appendix
Groin hernia repair
Bowel obstruction
Adhesion surgery
Colon resection
Hemorrhoid surgery
Anti-reflux surgery
Weight loss surgery
D&C
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C-section
Tubal ligation
Total hysterectomy
Partial hysterectomy
Ovarian surgery
Uterine ablation
Cone biopsy/LEEP
Benign breast biopsy
Lumpectomy
Mastectomy
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Vasectomy
Prostate surgery
Tonsillectomy
Sinus surgery
Cataract surgery
Lasik eye surgery
Arthroscopy
Knee replacement
Hip replacement
Back surgery
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Foot surgery
Stent/angioplasty
Heart bypass surgery
Heart valve surgery
Pacemaker
Defibrillator
Carotid surgery
Vascular surgery
Vein stripping
○ Any other surgeries not previously mentioned:_____________________________________________________
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SOCIAL HISTORY
Initials__________
Marital status: Single Married Separated Divorced Widowed Occupation:___________________
# of Children:__________ Years of Education:__________ Preferred Language:__________________
Do you use tobacco currently? ○ Yes ○ No
Did you ever use tobacco products? ○ Yes ○ No
When did you quit? ________
Number of packs per day? ________
How many years? ________
Do you drink alcohol? ○ Yes ○ No
How many glasses do you drink per day? ________
How many glasses do you drink per week? ________
Any problems with alcohol or drug use? ________
Do you drink caffeine? ○ Yes ○ No
Number of cups per day of caffeinated coffee? ________
Number of cups per day of caffeinated tea? ________
Number of cups per day of caffeinated soda? ________
REVIEW OF SYSTEMS
General
○ Fatigue
○ Weight loss
Eyes
○ Glasses
○ Contacts
Ears/Nose/Throat
○ Hearing loss
○ Ringing in ears
○ Weakness
○ Fever
○ Night sweats
○ Vision changes
○ Eye redness
○ Color blindness
○ Runny nose
○ Nosebleeds
○ Mouth sores
○ Tongue sores
Cardiovascular
○ Chest pain
○ Ankle swelling/edema
Respiratory
○ Cough
○ Palpitations
○ Varicose veins
○ Shortness of breath with exertion or sleep
○ Blue color changes in hands with cold
○ Shortness of breath
○ Wheezing
○ Abnormal skin pigment
○ Abnormal body hair
○ Dry skin
○ Dry hair
Lymph nodes (glands)
○ Swollen jaw
○ Swollen neck
○ Swollen underarm
○ Swollen groin
Bones/Joints/Muscles
○ Pain
○ Swelling
○ Stiffness
Endocrine
○ Intolerance to cold
○ Intolerance to heat
○ Coughing blood
○ Tooth/gum problems
○ Excessive sweating
○ Excessive hunger
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Initials__________
Skin
○ Itching
○ Rash
Neurologic
○ Headaches
○ Dizziness
○ Fainting
○ Tremor
Genitourinary
○ Blood in urine
○ Frequent urination
○ Bruising
○ Scaling
○ Localized numbness
○ Walking difficulty
○ Speech difficulty
○ Memory difficulty
○ Burning urination
○ Frequent urination at night
Males:
○ Slow urinary stream ○ Difficulty initiating urination
Females:
○ Abnormal periods
○ Breast lump(s)
○ Menopause
○ Breast pain
○ Dark urine
○ Urinary incontinence
○ Penile discharge
○ Breast enlargement
○ Vaginal discharge
○ Nipple discharge
FAMILY HISTORY
Father
Mother
Son
Daughter Brother
Sister
Grand
mother
Grand
father
Aunt
Uncle
Cousin
Colorectal
cancer
Colorectal
polyps
Celiac
disease
Crohn’s
disease
Ulcerative
colitis
H. pylori
Hemo
chromatosis
Hepatitis
B
Hepatitis
C
Stomach
cancer
Uterine
cancer
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Patient’s or Legal Guardian’s Signature
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Physician’s Initials
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Date
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Date
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