Patient Health History
Name_____________________________ Date of Birth_____________  Today's Date________

Please fill out the information below to provide us with background on your personal 
health history.

This information will remain confidential, and will be part of your patient record.

                                                                                                                      Thank you.

What is the purpose of your visit?

A.

Personal & Family History
Which of the following illnesses have you, or any of your blood relatives had?   
(Please check all that apply.)

                                                                

                                                                                              

I have had:     Relatives Had
Diabetes/High blood sugar

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High Blood  Pressure

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Heart attack (MI)/Angina/Arrhythmia

Angioplasty/stent

Pacemaker

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Lung Disease

Asthma/Emphysema/Pneumonia/TB

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Seizure/Stroke/TIA

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Cancer

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Thyroid Disease

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Ulcer/stomach or duodenum

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Hepatitis/Jaundice/Cirrhosis

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Gallbladder disease

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Pancreatitis

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Colitis/Crohn's  disease/Ulcerative colitis

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Bowel Obstruction/Adhesions

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Kidney or bladder Infection or Stone

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Depression/Anxiety/Panic attack/Bipolar disorder

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Sexually Transmitted Disease

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Tumor or Cancer

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Diverticulosis/Diverticulitis

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Colon polyps

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HIV Virus/AIDS block.gif (65 bytes)     block.gif (65 bytes)
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Anemia block.gif (65 bytes)     block.gif (65 bytes)
         
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Alcoholism        
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Please list allergies/adverse drug reactions: _________________________________________________________________________
_________________________________________________________________________________________
Any hx of anesthesia reaction or complication?
Which of these symptoms do you experiance on a regualr basis?   (Please check all that apply.)

                                                                

Heartburn

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Breathing and swallowing problems

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"Back-wash" of stomach contents into the mouth at night

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Morning hoarseness

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Upset stomach

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Abdominal pain

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Nausea or vomiting

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Gas, bloating or belching

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Diarrhea

Constipation

B.

HOSPITALIZATION
Please indicate below your most recent hospitalization.

Year

Operation/Illness

Hospital/Location
     
     
     


C.

MEDICATIONS
Are you currently taking prescription medication? block.gif (65 bytes)YES block.gif (65 bytes)NO

If yes, which medication(s)? ___________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Are you currently taking any over-the-counter medication?

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If yes, which medication(s)? ___________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

D.

PREGNANCIES
Are you pregnant now? block.gif (65 bytes)YES block.gif (65 bytes)NO block.gif (65 bytes)N/A
Have you been pregnant? block.gif (65 bytes)YES block.gif (65 bytes)NO block.gif (65 bytes)N/A
# of pregnancies_____     # of abortions_____     # of miscarriages_____    Contraceptive method______________________

E.

SOCIAL HEALTH HISTORY
Single/significant other/Separated/Divorced/Widow(er) block.gif (65 bytes) block.gif (65 bytes)
Do you have a regular exercise program? block.gif (65 bytes)YES block.gif (65 bytes)NO
Do you smoke? block.gif (65 bytes)YES block.gif (65 bytes)NO
               If yes, please list number of packs per day                                 _______________________________
Do you drink alcoholic beverages? block.gif (65 bytes)YES block.gif (65 bytes)NO
               If yes, please list amount/frequency:                                            _______________________________
Have you been outside the U.S. within the last 12 months? block.gif (65 bytes)YES block.gif (65 bytes)NO

         Please submit a copy of  your most recent complete laboratory test  results including Complete blood count & chemistry profile.Next page for comprehensive Hx form