Gastroenterology Clinic Patient History Form Page 3

ADVERTISEMENT

IV. GENERAL MEDICAL HISTORY
Diabetes
Yes - No
Arthritis
Yes - No
High Blood Pressure
Yes - No
Collagen Vascular Disease
Yes - No
Heart Murmur
Yes - No
Congestive Heart Failure
Yes - No
Dialysis
Yes - No
Mitral Valve Prolapse
Yes - No
Heart Disease
Yes - No
Kidney Disease
Yes - No
Lung Disease
Yes - No
Heart Valve Replacement/Disease Yes - No
Heart Attack
Yes - No
Sleep Apnea
Yes - No
Heart Stents
Yes - No
If yes, give date ________________
C-PAP Machine
Yes - No
If yes, give date ________________
Heavy Snoring
Yes - No
GI PAST MEDICAL HISTORY
HAVE YOU EVER HAD A COLONOSCOPY? YES - NO
Colon Polyps
Yes - No
Ulcer Disease
Yes - No
Liver Disease
Yes - No
Irritable Bowel Syndrome
Yes - No
Pancreatitis
Yes - No
Colon Cancer
Yes - No
Inflammatory Bowel Disease -
GI Bleeding
Yes - No
Reflux (GERD)
Yes - No
Other ______________________________
Ulcerative Colitis - Crohn’s
Yes - No
PAST SURGICAL HISTORY
Please list all operations you have had:
______________________________________________________
__________________________________________________________
______________________________________________________
__________________________________________________________
______________________________________________________
__________________________________________________________
______________________________________________________
__________________________________________________________
Do you have sleep apnea? ________ Do you use a C-PAP machine? _______ **Please bring your machine with you for your procedure
Have you ever experienced an adverse reaction (low blood pressure/heart rate, difficulty breathing, etc.) to intravenous sedations or
anesthesia?
Yes or No
If yes, for what operation/procedure _______________________________ Date of procedure ___________________________________
Blood Transfusion?
Yes or No
When? _________________________
Have you ever donated blood/plasma/platelets in the past? Yes or No If yes, year of last donation ______________________________
Have you ever been refused as a blood donor in the past?
Yes or No If yes, why? ___________________________________________
Radiation?
Yes or No
When? _________________________
Are you allergic to Lidocaine? Yes or No
Drug Allergies?
Yes or No
Are you allergic to eggs? Yes or No
Are you allergic to soy? Yes or No
Please List:
Are you allergic to latex? Yes or No
___________________________
___________________________ ___________________________ ___________________________
___________________________
___________________________ ___________________________ ___________________________
___________________________
___________________________ ___________________________ ___________________________
___________________________
___________________________ ___________________________ ___________________________
Are you currently taking prescription or over the counter medication?
Yes or No
List all medicines you are taking (prescription and non-prescription) Please list all pain medicine, sleeping pills or nerve pills you are
taking even if you only take them occasionally.
Medicine
Dosage
Times/day
Medicine
Dosage
Times/day
Medicine
Dosage
Times/day
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
Do you use alcohol
Yes or No
Amount ________________________________________________________________
Do you use tobacco
Yes or No
Packs per day ___________________________________________________________
Do you use drugs
Yes or No
Type ___________________________________________________________________
Do you have a family history of the following:
Who
Type (if known)
High Blood Pressure
Yes or No
__________________________
___________________________________________
Early Heart Disease
Yes or No
__________________________
___________________________________________
Diabetes
Yes or No
__________________________
___________________________________________
Cancer
Yes or No
__________________________
___________________________________________
Colon Polyps
Yes or No
__________________________
___________________________________________
Colon Cancer
Yes or No
__________________________
___________________________________________
Inflammatory Bowel Disease
Yes or No
__________________________
___________________________________________
Liver Disease
Yes or No
__________________________
___________________________________________

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form #10ll - Patient History Form Form #10ll - Patient History Form Medical
Patient History Form/history Of Present Illness/past Medical, Family & Social History Patient History Form/history Of Present Illness/past Medical, Family & Social History Education
Patient History Form/history Of Present Illness/past Medical & Social History Patient History Form/history Of Present Illness/past Medical & Social History Education
Patient History Form Patient History Form Medical
Patient History Form Patient History Form Medical
Patient History Form Patient History Form Medical
Patient History Form Patient History Form Medical
Patient History Form Patient History Form Business
Patient History Form Patient History Form Medical
Patient History Form Patient History Form Medical

Related Categories

Parent category: Medical
Download
Go
Page of 3