"Digestive Patient Intake Form - Elms Endoscopy Center"

ADVERTISEMENT
ADVERTISEMENT

Download "Digestive Patient Intake Form - Elms Endoscopy Center"

Download PDF

Fill PDF online

Rate (4.3 / 5) 19 votes
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 • ElmsDigestive.com
N
:______________________________ D
:________________ C
# ____________
ame
ate
hart
r
D
:____________________ P
C
D
:____________________
eferriNg
oCtor
rimary
are
oCtor
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
1
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 • ElmsDigestive.com
N
:______________________________ D
:________________ C
# ____________
ame
ate
hart
r
D
:____________________ P
C
D
:____________________
eferriNg
oCtor
rimary
are
oCtor
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
1
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
2
Page of 2