Digestive Patient Intake Form printable pdf download

Dr. Adelman • Dr. Florez • Dr. Goodear • Dr. New • Dr. Snyder

2671 Elms Plantation Boulevard, Charleston, South Carolina 29406 • Phone: (843) 797-6800 • Fax: (843) 797-6825

Medical Hours: Monday - Thursday 8:30 AM - 4:30 PM, Friday 8:30 AM - 12 Noon •

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Chief Problem (Reason for Visit):

Allergies: c Codeine c Penicillin c X-Ray Dye c Sulfa c Latex c Other_________________________

Current Medication and Dosages

Past Surgical History: c EGD Dates_________ c Colonoscopy Dates_________ c ERCP c Gallbladder

c Cardiac Catheterization c CABG (Bypass Surgery) c Colon Resection

Other Surgeries: ___________________________________________________________________________

Social History: c Caffeine Use c Illegal Drug Use c Tobacco Use c Alcohol Use c Retired c Full Time

c Part Time c Unemployed c Tattoos c Body Piercings c Traveling out of Country

Family History: c Colon Polyps c Colon Cancer c Esophageal Cancer c Stomach Cancer

c Liver Disease c Pancreatitis c Crohn’s Disease c Ulcerative Colitis c Endometrial Cancer

c Ovarian Cancer c Other_____________________

Past Medical History:

Cardiovascular Hx: c Cardiac Arrest c Cardiomyopathy (Enlarged Heart) c Angina

c Hypertension (High Blood Pressure) c Hyperlipidemia (Cholesterol) c Congestive Heart Failure

Childhood Illnesses: c Usual Childhood Illnesses

Dermatologic Hx: c SCC c Skin Problems c Warts c Acne c Dermatitis c Pruritus

Endocrine Hx: c Diabetes c Hypothyroidism c Hyperthyroidism c Osteoporosis

Genetic Background: c Autism c Cystic Fibrosis c Sickle Cell c Hemophilia

c Other_____________________

Gastrointestinal History: c Celiac Disease c GERD (Reflux) c History Colon Polyps

c Irritable Bowel Syndrome c Pancreatitis c Stomach or Bowel Problems c Ulcer

c Gall Bladder Problems c Diverticulosis c Diverticulitis c Crohn’s Disease c Colitis c Cancer

Digestive Patient Intake Form