Gastroenterology Clinic Patient History Form (Page 2 of 3) in pdf

PATIENT HISTORY FORM

NAME ___________________________________________________________________ DATE ________________________

AGE ____________ HEIGHT ___________ WEIGHT ___________ REFERRING DOCTOR ________________________

MAIN COMPLAINT - THE MAIN REASON YOU ARE SEEING THE DOCTOR TODAY: Check Only One

_____ Abnormal Liver Tests

_____ Constipation

_____ GERD-Heartburn-Indigestion

_____ Painful Swallowing

_____ Bloating

_____ Diarrhea

_____ Hepatitis

_____ Positive Stool Cards

_____ Blood in Stool

_____ Difficulty Swallowing

_____ Lower Abdominal Pain

_____ Upper Abdominal Pain

_____ Change In Bowel Habits

_____ Fever

_____ Nausea

_____ Weight Loss

_____ Vomiting

Other ________________________________________________________________________________

II. OTHER SYMPTOMS YOU ARE HAVING: PLEASE CIRCLE YES OR NO

Bloating

Yes - No

Diarrhea

Yes - No

Nausea

Yes - No

Blood in Stool

Yes - No

Difficulty Swallowing

Yes - No

Painful Swallowing

Yes - No

Change in Bowel Habits Yes - No

Fever

Yes - No

Upper Abdominal Pain

Yes - No

Constipation

Yes - No

Lower Abdominal Pain

Yes - No

Weight Loss

Yes - No

Other ___________________________________________________________________________________________________________

What specific concerns or questions would you like the physician to address? (Fear of cancer, hepatitis, etc.)

_________________________________________________________________________________________________________________

III. REVIEW OF SYSTEMS - IF YOU ARE CURRENTLY EXPERIENCING: PLEASE CIRCLE YES OR NO

CONSTITUTIONAL

CARDIOVASCULAR

INTEGUMENTARY

Fatigue

Yes - No

Chest Pain

Yes - No

Breast Discharge

Yes - No

Fever

Yes - No

Edema

Yes - No

Breast Lump

Yes - No

Loss of Appetite

Yes - No

Palpitation

Yes - No

Breast Pain

Yes - No

Night Sweats

Yes - No

Other _______________________________

Itching

Yes - No

Rigors

Yes - No

Rash

Yes - No

Weight Loss

Yes - No

GENITOURINARY

Other _______________________________

Weight Gain

Yes - No

Blood in Urine

Yes - No

PSYCHIATRIC

Other _______________________________

Difficulty Starting Urine Stream

Yes - No

Anxiety Disorder

Yes - No

Frequent Urination

Yes - No

Depression

Yes - No

EYES

Painful Urination

Yes - No

Panic Attack

Yes - No

Eye Pain

Yes - No

Other _______________________________

Sleep Disorder

Yes - No

Sudden Change in Vision

Yes - No

Other _______________________________

GYNECOLOGY

Other _______________________________

Abnormal Vaginal Bleeding

Yes - No

ENDOCRINE

Vaginal Discharge

Yes - No

Change In Hair Pattern

Yes - No

EARS-NOSE-MOUTH-THROAT

Is there any chance you could

Dry Skin

Yes - No

Bad Breath

Yes - No

be pregnant?

Yes - No

Heat/Cold Intolerance

Yes - No

Ears Ringing

Yes - No

Other _______________________________

Hearing Loss

Yes - No

Hoarseness

Yes - No

HEMATOLOGIC / LYMPHATIC

MUSCULOSKELETAL

Nose Bleeds

Yes - No

Anemia

Yes - No

Back pain

Yes - No

Post Nasal Drip

Yes - No

Bleeding / Bruising Tendency

Yes - No

Joint Pain

Yes - No

Enlarged Lymph Nodes

Yes - No

Sore Throat

Yes - No

Morning Stiffness

Yes - No

Other _______________________________

Raynaud’s

Yes - No

Other _______________________________

ALLERGIC / IMMUNOLOGIC

RESPIRATORY

Chronic Nasal Congestion

Yes - No

Cough

Yes - No

NEUROLOGICAL

Chronic Runny Nose

Yes - No

Shortness of Breath

Yes - No

Weakness on either side

Yes - No

Frequent Sneezing

Yes - No

Wheezing

Yes - No

Abnormal skin sensations

Yes - No

Watery Itchy Eyes

Yes - No

or sensitivity

Other _______________________________

Headaches

Yes - No

Other _______________________________

Gastroenterology Clinic Patient History Form Page 2

Related Articles

Related forms

Related Categories