Vanderbilt Digestive Disease Center
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Division of Gastroenterology
and Hepatology
IMPRINT
HERE
NAME:________________________________
**SPECIFIC REASON FOR THE VISIT: ______________________________________
DRUG ALLERGIES or SENSITIVITY: ________________________________________________
MEDICAL HISTORY (Year and Diagnosis)
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
OPERATIONS (Year and Procedure)
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
FAMILY HISTORY: Have any of your immediate family had any of the following:
Write the appropriate family member beside the condition (parent, children, brother, sister, uncle, aunt, grandparent)
Colon Cancer
_______ Thyroid Disease
_______
Rheumatoid Arthritis _______
Crohn’s Disease
_______ Kidney Disease
_______
High Blood Pressure _______
Ulcerative Colitis
_______ Heart Disease
_______
Auto Immune Disorders______
Liver Disease
_______ Lung Disease
_______
Other Cancer
_______
SOCIAL HISTORY:
Do you smoke:
YES NO
Packs per day: _______
How many years: _______
Do you drink:
YES NO
Amount per day/week/month _______ How many years ______
Marital Status:
__________________
Occupation: ____________________________
Number of Children ______
Do you have a Caregiver?
_______________________________
Digestive Disease Center
Phone: (615) 322-0128
D:\106740474.doc
1660 The Vanderbilt Clinic
Nashville, Tennessee 37232-5280
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2/13/2016
Vanderbilt Digestive Disease Center
MEDICAL HISTORY:
If any of the listed symptoms have been a severe or frequent
problem for you, please indicate this by CIRCLING the appropriate symptom (s).
GENERAL:weight loss or gain, night sweats, fevers, chills
HEAD:
trauma, dizziness, fainting, seizures, headaches
EYES:
decreased vision, color blindness, double vision, blurred vision, swelling or
puffiness underneath the eyes
EARS, NOSE, MOUTH, THROAT: pain, deafness, discharge, ringing of ears, vertigo, sinus discharge,
nose bleeds, hay fever, sore throat, tonsillitis, hoarseness
CARDIOVASCULAR:
palpitations, chest pain, shortness of breath with activity, fatigue, swelling in
legs or feet, high blood pressure, heart murmur or attack
RESPIRATORY TRACT:
cough, excessive sputum, asthma, coughing of blood, pleurisy
GASTROINTESTINAL:
painful swallowing, nausea, vomiting, vomiting of blood, indigestion, yellow
jaundice, hepatitis, excessive use of laxatives, diarrhea or constipation
RECTAL:
change in bowel habits, bloody stools, tarry stools, clay colored stools,
hemorrhoids
GENITOURINARY:
kidney or bladder problems, pain with urination, inability to urinate, blood in
the urine
MUSCULOSKELETAL:
deformities of bones/joints, weakness, trauma, limitation of movement
SKIN:
changes in texture/color of moles or skin, hives/rash, itching/scaling, bruising
BREAST:
trauma, lumps, pain, nipple discharge, infections
NEUROLOGIC:
paralysis, weakness, involuntary movements, convulsions, in-coordination,
numbness, or tingling of extremities
PSYCHIATRIC:
anxiety, depression, hallucinations, uncontrollable stress, phobias
ENDOCRINE:
excessive weight gain or loss, change in appetite, goiter, excessive thirst,
excessive urination, thyroid problems or diabetes
HEMATOLOGIC or LYMPHATIC; excessive bleeding, swollen lymph nodes, bleeding disorders, previous
blood transfusions
IMMUNOLOGIC:
immune disorders, HIV, immunosuppressant
GYNECOLOGIC:
irregular menses, menopause, hormone therapy
Reviewed with Patient _______________________________________________________M. D.
Date: _______________________
Digestive Disease Center
Phone: (615) 322-0128
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1660 The Vanderbilt Clinic
Nashville, Tennessee 37232-5280
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Vanderbilt Digestive Disease Center
Current Medications (to include over the counter drugs)
NAME:
______________________________________________________
Date of Birth: ______________________________________________________
Name of Drug
Dose
Frequency
Strength (such as mg, cc)
How many times a day?
Referring Physician: _______________________________________
Referring Physician Phone #: _______________________
Digestive Disease Center
Phone: (615) 322-0128
D:\106740474.doc
1660 The Vanderbilt Clinic
Nashville, Tennessee 37232-5280
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2/13/2016