ASSOCIATES IN GASTROENTEROLOGY, PC
THE ENDOSCOPY CENTER OF COLORADO SPRINGS, LLC
Colorado Springs, Co. 80909 Office 719-635-7321 Endoscopy Center 719-785-3500
PATIENT INFORMATION SHEET
Name________________________________ Sex: F M DOB____________ Age_______ Date _______
Marital status: Single______ Married____ Divorced____ Widowed_____ Number of Children__________
Physician: (Please circle) Wenham
Van Os
Lunt
Howden
Garza Cesario
Barnett PA
Primary Care Physician_________________________
It is important for our physicians / PAC to have your complete health history. Please help us by taking the time to provide this
information accurately and completely. This information will be a confidential part of your medical record.
PAST SURGICAL AND MEDICAL HISTORY—(Circle Yes or NO) If yes, Date of onset, comments.
YES NO
YES NO
MEDICAL HISTORY
Onset, Comments
SURGICAL
Date, Comments
HISTORY
Yes No
Yes No
Anorexia / Bulemia
Colon
Yes No
Yes No
Arthritis / Joint swelling
Stomach
Yes
No
Yes No
Asthma
Heart:
Yes No
Yes No
Stent / Bypass
Bleeding disorder
Yes No
Yes No
Valve
Blood or infectious disease
Yes
No
Yes No
Pacemaker
Cancer, Type:
Defibrillator
Yes No
Yes No
Colon polyps
Yes
No
Joint replacement Yes No
Crohn’s disease
Yes No
Yes No
Diabetes
Gallbladder
Yes No
Yes No
Epilepsy / seizures
Hysterectomy
Yes
No
Yes No
Gallstones
Appendix
Yes No
Yes No
Glaucoma
Prostate
Yes
No
Yes No
Headaches/ fainting/ dizziness
Bladder
Yes No
Yes No
Heart problems/ Chest pain
C-section
Yes
No
Yes No
Hepatitis / Liver problems
Breast
Yes No
Hiatal hernia / GERD
Other surgeries
Yes No
High / low Blood pressure
Other surgeries
Yes
No
Kidney disease
Other surgeries
Yes No
Lung Disease
Other surgeries
Anesthesia Problems
Yes
No
Yes No
Pacemaker / Internal defibrillator
Yes No
Previous EGD
Yes No
Sleep Apnea
Yes
No
Prev
Colonoscopy
Yes No
Stomach problems / ulcers
Yes No
Stroke
Vaccinations (yes or No, and date)
Yes
No
Hepatitis A
Yes No
Thyroid problems
Yes No
Hepatitis B
Yes No
Tuberculosis
Yes
No
Ulcerative Colitis
Other
Other
Other
CURRENT MEDICATIONS: Please include vitamins, herbs, and pain relievers AND RECENT ANTIBIOTICS
Medication
Dosage
Times per day
Medication
Dosage
Times per day
ALLERGIES
REACTION
ALLERGIES
Over please
REACTION
ALLERGIES
REACTION
Page 1
ASSOCIATES IN GASTROENTEROLOGY, PC / THE ENDOSCOPY CENTER OF COLORADO SPRINGS, LLC
Colorado Springs, Co. 80909 Office 719-635-7321 Endoscopy Center 719-785-3500
Name________________________________ Sex: F M
DOB____________ Age_______ Date _______
SOCIAL HISTORY: (Past or Current)
Alcohol
Coffee / Caffeine
Substance Abuse
Tobacco
Blood Transfusions
Tattoos
Do you exercise?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Quit
Quit
Quit
Quit
When?
Duration &
Duration &
Duration &
Duration &
Amount
Amount
Amount
Amount
How much?
FAMILY HISTORY: Please indicate any RELATIVES with the following diseases.
Alcoholism
Cirrhosis / Jaundice
Colon Cancer
Colon or rectal polyps
Crohn’s/Ulcerative Colitis
Diabetes
Gallstones
Hemachromatosis
Heart disease
High Blood Pressure
Liver Disease
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
SYMPTOM REVIEW Check () symptoms you currently have or have had in the past
 Weight Loss
 Cough
 Frequent urination
 Memory loss
 Fever/Chills
 Shortness of breath
 Incontinence of urine  Depression
 Poor vision/double vision  Heart burn
 Difficulty urinating
 Anxiety
 Dry mouth
 Nausea / vomiting
 Blood in urine
 Hair loss
 Frequent nosebleeds
 Swallowing difficulties
 Arthritis/Joint pain
 Hot/Cold sensitivity
 Hearing loss
 Pain with swallowing
 Muscle aches
 Excessive thirst
 Nasal congestion
 Abdominal pain
 New or chronic rash
 Easy bruising
 Hoarseness
 Diarrhea
 Nail changes
 Excessive bleeding
 Chest pain
 Constipation
 Headaches
 Swollen lymph nodes
 Irregular heart beat
 Blood in stool
 Seizures
 Swelling of ankles/legs
Other:
Other:
Physician notes if needed:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Other Physicians Who Are Actively Treating You:
Doctor:
Condition:
Doctor:
Condition:
REVIEWED BY:
DATE:
If this form was filled out more than 30 days ago patient and
physician will review and update:
Patient Signature:
signature:
Patient Signature:
signature:
Physician / PAC Signature
Date:

No changes
Date:

No changes
Physician
Changes made.
Physician
 Changes made.
