Patient Health History Form NameAgeHeightWeightPlease state the main reason(s) you have an appointment with our office.GI Review of Systems Have you recently had any of the following symptoms?1. Have you had recent pain in your upper abdomen?YesNo2. Do you have pain in the upper abdomen that you can locate with one finger?YesNo3. Does your pain spread throughout your upper abdomen?YesNo4. Do you have difficulty swallowing food or liquids?YesNo5. Do you have heartburn? (burning in your chest or throat)YesNo6. Do you have chest pressure or tightness?YesNo7. Do you notice any of the following testes in your mouth?metallicbitteracidsournone8. Do you often have a hoarse voice?YesNo9. Do you often have to clear your throat of mucus?YesNo10. Do you often cough?YesNo11. Do you have difficulty swalowing ...liquidssolid foodtabletsNo12. Does it hurt when swallow?YesNo13. Do you feel bloated ofter a meal?YesNo14. Do you feel bloated in your upper abdomen?YesNo15. Do you have difficulty completing you meals?YesNo16. Do you feel as if you might vomit after a meal?YesNo17. Do you vomit after a meal?YesNo18. Have you vomited blood?YesNo19. Do you fell sick at other times of the day?YesNo20. Do you get pain in your upper abdomen after eating fatty or greasy foods?YesNo21. Do you belch more then normal?YesNo22. Does abdominal pain wake you up at night?YesNo23. Is the pain in your abdomen relieved by eating?YesNo24. Is the pain relieved by taking over-the-counter antacids?YesNo25. Do you have pain in your lower abdomen?YesNo26. Is this pain relieved by bowel movements or passing gas?YesNo27. Have you had a recent change in the frequent, shape or consistency of your bowel movements?YesNo28. Have you had recurrent diarrhea, or do you have continuous diarrhea?YesNo29. Have you recently had problems with an episode of constipation, or do you have frequent or chronic constipation?YesNo30. Have you recently had an urgent need to have a bowel movement that makes you rush to the toilet?YesNo31. Do you sometimes not make it to the toilet in time?YesNo32. Do you have to strain while having a bowel movement?YesNo33. Do you have rectal pain in association with a bowel movement, or at any other time such as in the middle of the night?YesNo34. Have you felt unable to complete your bowel movement?YesNo35. Do you see blood?on the toilet paperon the surface of the stoolmixed in with the stoolin the water of the toilet bowlNo36. Do you have black tarry stools?YesNo37. Do you see mucus in your stool?YesNoGastrointestinal History Check if you currently have OR have had any of the following: UIcerative colitis Crohn's colitis Crohn's enteritis (small intestine) Crohn's ileocolitis (small intestinal and colon) Gallstones Gallbladder disease Fatty liver disease Hepatitis Cirrhosis of the liver Liver cysts or tumor Pancreatic problems Colon polyps H. pylory stomach infection Esophageal problems Peptic ulcer Acid reflux Gastrointestinal bleeding Anemia Blood transfusion - when? Cancer Colon Rectal Liver Pancreas Stomach Esophageal Anal Other Alcohol-related illness Anorexia nervosa Bulimia Lactose intolerance Celiac disease Irritable bowel syndrome Hemochromatosis Hemorrhoids Anal fissure/fistula Enema use Diverticulosis Diverticulitis Chronic constipation Chronic diarrhea Colon polyps NONE Check if you have undergone Colonoscopy Upper endoscopy Sigmoidoscopy None If not performed by Dr. Marcus:a) Who performed this procedure?b) Where was the procedure performed?c) When was it performed?d) What was found?General Medical Conditions Check if you currently have OR have had any of the following: AIDS Anxiety disorders Arthritis Asthma Atrial fibrillation or other arrhythmias Bleeding disorders Blood clotting disorders Chicken pox Chronic bronchitis Congestive heart failure COPD Dementia Depression Diabetes (non-insulin-dependent) Diabetes (insulin-dependent) Drug abuse Electrolyte imbalance Emphysema Epilepsy Goiter Gout Heart attack Heart disease Heart murmur Herpes High cholesterol HIV positive Hypertension Kidney disease Kidney stones Migraine headaches Multiple sclerosis Osteoporosis Pacemaker Pneumonia Prostate problems Psychiatric care Rheumatic fever Sleep apnea Seizure disorders Stroke Tubercoulosis Positive PPD TB test Problems with anesthesia Valvular heart disease Multiple drug allergies Severe allergic reactions Cancer Breast Thyroid Prostate Skin Other NONE Check any surgeries you have had and state the approximate year. Appendix Breast CABG Cataract Cesarean delivery Colon/Bowel D&C Esophagus Gallbladder Hemorrhoids Hernia Hysterectomy Orthopedic Ovarian Pancreas Prostate Stent placement Stomach Tonsils Tubal ligation Other Appendix YearBreast YearCABG YearCataract YearCesarean deliveryColon/Bowel YearD&C YearEsophagus YearGallbladder YearHemorrhoids YearHernia YearHysterectomy YearOrthopedic YearOvarian YearPancreas YearProstate YearStent Placement YearStomach YearTonsils YearTubal ligation YearOther YearList any other hospitalizations, illnesses or possible conditions:Medication List None Have you taken any antibiotics in the past 30 days?YesNoWhich drug?Do you take:Blood thinners?YesNoAspirin?YesNoFish oil?YesNoVitamins?YesNoHerbals?YesNoName of medicationDoseHow often Do you routinely take over-thecounter medications?YesNoMedication Allergies Are you allergic to:Penicillins?YesNoSulfa drugs?YesNoOther medications?YesNoPlease list:Personal HabitsTOBACCO:Have you ever smoked cigarettes regularly?YesNoIf yes, what age did you start?What age did you stop?Number of cigarettes per day?Number of years you smoked?ALCOHOL:Do you drink every day?YesNoHow many drinks per week?Have you ever felt badly about something that happened because of you drinking?YesNoRECREATIONAL DRUGS:Do you use or have you used recreational drugs?YesNoWhich ones?Do you have any dietary restrictions?YesNoPlease check all that are appropriate Vegetarian Vegan Lactose intolerance Diet free of red meat Gluten Other Sexual History - RelationsDo you preferManWomenBothAbstinentHeve you had relations with someone who is sexually promiscuous or who has HIV/AIDS?YesNoSocial HistoryWhere were you born?Relationship StatusSMPDWDo you have any children?Please list your current or past professions:Family HistoryWhere was your mother born?Age if livingor age of deathWhere was your father born?Age if livingor age of deathPlease indicate who in your family may have had the following? M = Mother F = Father S = Sibling GP = Grandparent C = ChildCancerCeliac disease M F S GP C Breast M F S GP C Hypertension M F S GP C Colitis M F S GP C Esophageal M F S GP C Stroke M F S GP C Crohn's disease M F S GP C Stomach M F S GP C Heart disease M F S GP C Colon polyps M F S GP C Pancreas M F S GP C Diabetes M F S GP C Liver disease M F S GP C Liver M F S GP C Arthritis M F S GP C Hepatitis B or C M F S GP C Colon M F S GP C Osteoporosis M F S GP C Peptic ulcer disease M F S GP C OtherAnemia M F S GP C Alcoholism M F S GP C Drug addiction M F S GP C Have any of your blood relatives had colon or rectal cancer?YesNoWho?Age the cancer was diagnosedHave any of your blood relatives had colon polyps?YesNoWho?Have any of your blood relatives had gastric or esophageal cancer?YesNoWho?Review of SymptomsGeneral: Loss of appetite Recent weight loss or gain Fevers Weakness OtherSkin: Itching Rash Other skin disorderEars: Infections Loss of hearing Eyes: Redness Cataracts Glasses OtherNose: Nosebleeds Chronic postnasal drip Hay fever OtherMouth and Throat: Bleeding gums Sore throats Hoarseness Mouth sores Chest: Cough Sputum Breathlessness Coughing blood Wheezing Heart: Chest pain Palpitations Shortness of breath Breathlessness when lying down Waking up breathless from sleep Ankle swelling OtherUrinary: Increased frequency Blood in urine Pain with urination Urinate more than 2 times at night OtherMusculoskeletal: Joint pain Joint swelling Muscle weakness or pain OtherEndocrine: Excess thirst Heat or cold intolerance OtherNeurologic: Headaches Loss of consciousness Seizures Persistent tingling Numbness Paralysis OtherHematologic: Easy bruising Excessive bleeding if cut or after dental extractions Female (dates):Last normal menstrual periodLast mammogramLast Pap smearLast DEXA bone scan