Digestive Patient Intake Form (Page 2 of 2) in pdf

GYN/Urology: c Kidney Disease c Kidney Stones c Dialysis c Renal Failure

c Prostate Cancer c Breast Cancer

Ear/Nose/Throat c Halitosis (Bad Breath) c Allergic Rhinitis (Sinus Problems)

Hematologic/Lymphatic Hx: c Anemia c Thrombocytopenia (Low Platelets) c Enlarged Spleen

c Pancytopenia c Blood Clotting Abnormalities c Bleeding Tendencies c Blood Transfusions

Immunologic HX: c Tuberculosis c Transplant Rejection c Systemic Lupus Erythematosus (SLE)

c Rheumatic Fever c HIV/AIDS

Musculoskeletal Hx: c Bursitis c Gout c Arthritis Conditions c Fibromyalgia

c Musculoskeletal Problems c Back Pain

Neurological Hx: c Migraines c Seizure Disorders c Stroke c Alzheimer’s Disease

Psychiatric Hx: c Depression c Anxiety c Bipolar c Anxiety Disorder

Respiratory Hx: c COPD c Lung Cancer c Sleep Apnea c CPAP c Asthma c Respiratory Failure

c Emphysema c Chronic Lung Disease

Vaccination Hx: c Influenza c Pneumovax

Review of Systems (Symptoms):

Cardiovascular: c Heart Palpitations c Tightness in Chest

Constitutional Symptoms: c Weight Loss, Unintentional

Ears, Nose, Mouth, Throat: c Cough c Sore Throat

Endocrine: c Polyuria

Eyes: c Loss of Vision c Transient Visual Loss

Gastrointestinal: c Abdominal Pain c Bloating c Change in Bowel Habits c Constipation

c Diarrhea c Dyspepsia (Upper Stomach Pain) c Dysphagia (Trouble Swallowing) c Epigastric Pain

c Eructation c Excess Gas c Fecal Incontinence c Heartburn c Hematemesis c Hematochezia

c Indigestion c Loss of Appetite c Melena c Mucous in Stool c Nausea

c Post Prandial Emesis (After Meal Vomiting) c Rectal Bleeding c Rectal Pain c Reflux

c Tenesmus c Vomiting c Weight Loss-Intentional c Yellowing of Skin

Genitourinary: c Bloody or Brownish Urine c Stress Incontinence

Hematologic/Lymphatic: c Bleeding Tendency c Fever c Leg Swelling

Integumentary (Skin): c Dermatitis (Skin Lesions) c Urticaria (Hives) c Itching

Musculoskeletal: c Arthralgia c Back Pain (chronic)

Neurological: c Confusion c Recent Seizure

Psychiatric: c Depression c Poor Sleep pattern

Respiratory: c Breathing Difficulty c Shortness of Breath

Digestive Patient Intake Form Page 2