Gastroenterology Consultants of Greater Lowell
Patient Medical and Surgical History
Name: _________________________________Age: __________Date: _______________
Primary Care M.D. _____________________________________________________________________
Reason for Today’s Visit ________________________________________________________________
Medications
Please list all current medications, including over the counter medications and supplements
_____________________________________________________________________________________
_____________________________________________________________________________________
Drug Allergies
Drug Allergies, please write them here.
_____________________________________________________________________________________
Medical History
Please check all areas that apply to your medical history.
__ heart attack
__ lung disease
__ gallbladder
__ hiatal hernia
__ cancer
__ chest pain
__ asthma
__ liver disease
__ gastric reflux
__ arthritis
__ Heart murmur
__ tuberculosis
__ jaundice
__ diabetics
__ psychiatric
__ blood pressure problems
__ emphysema
__ hepatitis
__ thyroid problems __ blood clot
__ kidney disease
__ seizure
__ anemia
__ shortness of breath __ ulcers
__ prostate problems
__ stroke
__ bowel problems __ bleeding problems
__ high cholesterol
Surgical History
Please list all previous major surgeries
_____________________________________________________________________________________
_____________________________________________________________________________________
If you had surgery, did you have any problems with anesthasia? Please describe. __________________
___________________________________________________________________________________
Social History
Do you smoke?
Y/N number of years ______
History of drug addiction or use of illegal drug. Y/N
Do you drink alcohol? Y/N How Often? _____________ Do you have a history of sleep apnea? Y/N
Married __
Divorced __
Single __
Widowed __
Number of Children ____
Work status: Homemaker: __ Working __ Unemployed __ Retired __ Disabled __
Occupation ____________________________________________________________________________
Family History
Do you have a family history of Colon Cancer? Y/N (father, mother, siblings, or children)
Do you have a family history of Colon Polyps? Y/N (father, mother, siblings, or children)
Gastroenterology Consultants of Greater Lowell
Are you experiencing any of the following (Please check all that apply):
Do you consider yourself generally:( ) Healthy ( ) Not Healthy (
) Other _______________
Allergic: ( ) Eye Irritation ( ) Reactions ( ) Sneezing ( ) Other _________________
( ) None
Eyes:
( ) None
( ) Blurred Vision
Ears, Nose, Throat, Mouth:
Endocrine:
( ) Pain
( ) Nose Blocked
( ) Post Nasal Drip
( ) Teeth Pain
( ) Cold Intolerance
( ) Hot flashes
Respiratory/Lungs:
( ) Irritation from Light ( ) Other __________
( ) Itching
( ) Pressure is Ears
( ) Runny Nose
( ) Other ____________
( ) None
( ) Hair Loss/Growth
( ) Heat Intolerance
( ) Other ____________________
( ) None
( ) Cough
( ) Asthma or COPD ( ) Shortness of Breath while sitting
( ) Wheezing ( ) Other __________________
( ) None
Cardiovascular/Heart: ( ) Pain in Chest
( ) Palpitations/Fluttering of Heart
( ) Shortness of Breath while exercising
( ) Other __________
Gastroenterology/Stomach:
( ) Pain
( ) Constipation
( ) Diarrhea
( ) Reflux/Heartburn
( ) Other: _________________
Hematology: ( ) Bleed Easily
( ) Night Sweats
( ) Weight Loss
Genitourinary: ( ) Urination at Night ( ) Hesitation when urinating
( ) Other ___________________
Musculoskeletal: ( ) Soreness
( ) Weakness
( ) Cramping
Skin: ( ) Sores
( ) Dry Skin ( ) Itchy Skin ( ) Rash
( ) Other ____________________
( ) None
( ) None
( ) Other ________ ( ) None
( ) Pain when urinating
( ) None
( ) Other __________ ( ) None
( ) Lesions Where___________
( ) None
Neurologic:
( ) Twitch
( ) Ringing in ears ( ) Abnormal movements ( ) Headaches
( ) Dizziness/Vertigo ( ) Fainting ( ) Other __________________
( ) None
Psychiatric:
( ) Situational Stress ( ) Anxiety
( ) Other ___________
( ) Depression
( ) Mood Swings
( ) None