COMMONWEALTH GASTROENTEROLOGY, PLC

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NOTHERN VIRGINIA GASTROENTEROLOGY, P.C

Gastroenterology History Form

Name: _______________________________________________________ Date: __________________

Referring Physician/ Primary Care Physician: ________________________________________________

Date of Birth: _____________

Reason for Visit:

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Medical History: Please check any of the conditions that represent a significant problem for you

GENERAL

Fever

YES GASTROINTESTINAL

Abdominal pain

YES MUSCULOSKELETAL

Recent Fractures

YES

Chills

Night Sweats

Recent Weight Changes

EYES

Glasses

Contacts

Glaucoma

Nausea

Vomiting

Heartburn

YES Indigestion

Pain with Swallowing

Difficulty Swallowing

Diarrhea

Muscle Aches/Pains

Arthritis

ENDROCRINE

Heat intolerance

Cold intolerance

Hot flashes

Excessive thirst

YES

Eye dryness

Eye redness

Irregular heart beat

Heart attack or failure

Heart murmur

Heart valve problems

Blood clots

Leg /Ankle swelling

Constipation

Blood in Stool

Eye pain Pain with having a BM

EARS, NOSE, MOUTH YES Gallbladder Problems

Nose bleeds

Sinus problems

Earache

RESPIRATORY

Cough

Wheezing

YES

Loss of appetite

Gas/Bloating

Black Stool

GENITOURINARY

Painful urination

Urinary Urgency

Shortness of breath

Asthma

Blood in urine

Recurrent bladder infections

CARDIOVASCULAR YES Abnormal vaginal bleeding

Chest pain Sexual problems

Heart palpitations Menstrual problems

Flushing

Changes in body hair

SKIN

Rash

Dryness

Itching

Jaundice

YES Easy bruising

Psoriasis

Eczema

Pigment changes

NEUROLOGIC

Numbness

Dizziness

Paralysis

PYSCHIATRIC

Depression

Anxiety

OTHER

YES

YES

YES

Please list all of your medications, including over the counter medications (If you need additional space, please bring a list to your appointment.) Include Medication Name, Dosage and Number of times per Day

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Please list all allergies including medications, food, and environmental

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Past Medical History: Please list any medical conditions you have been diagnosed with or are being treated for:

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Number of Pregnancies ________ Number of Live Births _______

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Pneumonia Vaccine __________________Flu Shot ____________________

Hepatitis A Vaccine _______________ Hepatitis B Vaccine __________________ TB Skin Test ________________

Please list any past surgeries

Date Surgeries

Family History (If a relative has had cancer, please specify type)

Relative Age Living Deceased Disease or Cause of death

Social History:

Marital Status: Single ___ Divorced ___

Married ___ Widow/Widower ____Other __

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Do you smoke? Yes __

No __

If yes, how many packs per day?_________________________________

Did you smoke? Yes __

No __

If yes, when did you quit? ______________________________________

Do you drink alcohol? Yes ___

No ___

If yes, indicate on average how much and circle day, week, or month:

_______Beer per: Day __

Week ___

Month ___

_______Glasses of wine per: Day ___

Week ___

Month __

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_______Mixed drinks per: Day ___

Week ___

Month ____

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Do people get annoyed by your drinking? Yes __

No ___

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Do you feel guilty about drinking? Yes __

No ___Do you drink alcohol in the morning? Yes __

No __

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Do you or have you ever-used intravenous (IV Drugs)? Yes __

No __

Do you have Tattoos? Yes __No __

DO YOU HAVE ANY OTHER PROBLEMS YOU WANT TO DISCUSS? Yes ___

No ____

Caffeine Use: Please indicate how much of caffeine you consume below:

(Caffeinated beverages include coffee, tea, green tea, sodas, chocolate, energy drinks)

Caffeinated beverages per: Day_____ Week_____

Patient signature_______________________________________________ Date ___________________________

Physician signature _____________________________________________Date ___________________________

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