Northeast Digestive Health Center

Health History

Name:		Date of Birth:
Address:		Employer Address:
Home Phone:		Employer Name:
Work Phone:		Primary Care Physician:
Spouse's Name:		Referring Physician:

Emergency Contact Name & #:
Relationship:

What is your main problem today?

Do you have any of the following:
- Swallowing problems	Yes No
- Nausea/vomiting	Yes No
- GERD (Reflux)	Yes No
- Heartburn/indigestion	Yes No
- Abdominal pain	Yes No
- Blood in stool	Yes No
- Black stool	Yes No
- Diarrhea	Yes No
- Constipation	Yes No

PAST MEDICAL HISTORY
Do you have any of the following:
- Heart Disease	Yes No
- High blood pressure	Yes No
- Diabetes	Yes No
- Stroke	Yes No
- Cancer	Yes No
- Colon Polyps	Yes No
- Ulcer	Yes No
- Liver disease	Yes No
- Pancreatitis	Yes No
- Intestinal blockage	Yes No
- Mental Illness	Yes No
- Bleeding problems	Yes No
- Diverticulitis	Yes No
- Seizure	Yes No
- Lung problems	Yes No
- Gall Bladder Disease	Yes No

FAMILY HISTORY
Does any of your immediate family (father, mother, brother, sister) have:
- Colon Cancer	Yes No
- Stomach Cancer	Yes No
- Pancreatic	Yes No
- Colon Polyps	Yes No
- Ulcerative colitis	Yes No
- Crohn's disease	Yes No
- Liver disease	Yes No
- Bleeding problems	Yes No

SOCIAL HISTORY
Do you smoke cigarettes or chew snuff?	Yes No
If yes, how many packs/day: # Years:
Do you drink alcohol?	Yes No
If yes, how much: # Years:
Use illicit drugs?	Yes No
What drug?
Do you use caffeine?	Yes No

CURRENT MEDICATIONS

Please include medication Name, Dose and Frequency

Do you take any blood thinners, aspirin, or arthritis medication?
Any problems with Anesthesia?	Yes No

REVIEW OF SYSTEMS
Do you currently have any of the following problems?
Fever	Yes No	Joint pain/swelling	Yes No
Night Sweats	Yes No	Walking difficulty	Yes No
Weight Loss/Gain	Yes No	Back pain	Yes No
Fatigue	Yes No	Muscle cramps/pain	Yes No
Appetite change	Yes No
		Rash	Yes No
Sore throat	Yes No	Itching	Yes No
Blurry/double vision	Yes No	Breast lump(s)	Yes No
Nose bleeds	Yes No	Skin cancer	Yes No
Hearing loss/ringing	Yes No
Hoarseness	Yes No	Dizziness	Yes No
Sinus problem	Yes No	Frequent headaches	Yes No
		Seizures	Yes No
Chest pain	Yes No	Numbness/tingling	Yes No
Swelling legs	Yes No	Fainting	Yes No
Palpitations	Yes No
		Memory loss	Yes No
Cough	Yes No	Sleeping problems	Yes No
Coughing blood	Yes No	Anxiety	Yes No
Shortness of breath	Yes No	Depression	Yes No
Wheezing	Yes No	Confusion	Yes No

Blood in urine	Yes No	Cold intolerance	Yes No
Painful urination	Yes No	Heat intolerance	Yes No
Frequent urination	Yes No	Excessive thirst	Yes No
Urine leakage	Yes No	Thyroid problems	Yes No
Kidney Stones	Yes No
		Female:
Anemia	Yes No	Date of LMP:
Easy bruising	Yes No	Vaginal discharge	Yes No
Transfusion	Yes No	Abnormal bleeding	Yes No
Swollen lymph glands	Yes No	Pain with periods	Yes No
		May be pregnant	Yes No