Child And Pediatric Health History Form
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4MRN:
UNIVERSITY OF MICHIGAN HOSPITALS & HEALTH CENTERS
NAME:
Gastroenterology
BIRTHDATE:
Health History Questionnaire - New Patient
-Gastroenterology
CSN:
Date of appointment _____/_____/__________ (mm/dd/yyyy)
Please fill this form out as completely as possible and bring this to your appointment.
Past Medical History (please check any medical problems that you have had in the past):
☐Anemia
☐Depression
☐Kidney stones
☐Anticoagulation therapy
☐Diabetes mellitus
☐Liver disease
☐Anxiety
☐Fatty liver
☐Myocardial infarction (heart attack)
☐Arthritis
☐Fibromyalgia
☐Osteoporosis
☐Cancer
☐GERD (heartburn)
☐Pancreatitis
☐Cataracts
☐Heart disease or pacemaker
☐Primary biliary cirrhosis
☐Chronic lung disease
☐Hepatitis B
☐Primary sclerosing cholangitis
☐Cirrhosis
☐Hepatitis C
☐Rashes/ skin problem
☐Colon polyps
☐Hyperlipidemia (high cholesterol)
☐Renal insufficiency
☐Congestive heart failure
☐Hypertension (high blood pressure)
☐Sleep apnea
☐Coronary artery disease
☐Inflammatory bowel disease
☐Thyroid disease
☐Crohn’s disease
☐Irritable bowel syndrome
☐Ulcerative colitis
☐Deep vein thrombosis
☐Kidney disease
☐Other (specify)_________________
Past Surgical History (Check any surgeries you have had and the date of surgery if you know it):
☐Appendectomy
☐Cosmetic surgery
☐Hysterectomy
☐Bariatric surgery
☐C-Section
☐Kidney transplant
☐Bowel resection
☐Eye surgery
☐Liver transplant
☐Breast surgery
☐Heart surgery
☐Orthopedic surgery
☐Cholecystectomy
☐Sterilization
☐
Hepatobiliary surgery
(gall bladder removal)
☐Colonoscopy
☐Hernia repair
☐Vascular surgery
☐Other (specify)_____________________
FOR OFFICE STAFF: COLLECTED INFORMATION MUST BE ENTERED IN MICHART.
DISCARD FORM AFTER ENTRY, USING CONFIDENTIAL RECYCLE. DO NOT SEND TO HIM.
Page 1 of 4
Health History Questionnaire - New Patient
VER: A/12
50-10079
Do Not File
HIM: 08/12
- Gastroenterology
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