GASTROENTEROLOGY

PATIENT QUESTIONNAIRE - PLEASE PRINT	

Full name:                                                                                                                Age:                                             Date:                                                        Address:                                                                                                       Telephone Number:                                                           Email address:                                                                    CHIEF COMPLAINTS(List the problems about which you came to see the doctor)
1)                                                                                                                                                                                  

2)                                                                                                                                                                                  

3)                                                                                                                                                                                   Referring Physician                                                                        Other Physician                                                     What pharmacy would you like us to call to fill your prescriptions:                                                                               	
PAST MEDICAL HISTORY	
Please check any of the following medical illnesses that you NOW have, or list any others that are not listed
below.	
 Change in appetite	 Pus or mucus in stool	 Itching
 Weight gain or loss	 Rectal bleeding	 Pain in relationship to eating
 Painful swallowing	 Tarry black stool	 Stomach pain relieved by food or
 Heartburn	 Rectal pain or itching	milk
 Nausea	 Painful bowel movements	 Feel full quickly
 Vomiting	 Abdominal swelling	 Problems controlling bowel
 Abdominal pain	 Jaundice or yellow eyes	movements
 Constipation	 		 	
 Diarrhea	
Please check any of the following medical illnesses that you have EVER had.	
 Ulcer	 Gallbladder disease	 Crohn’s
 Hepatitis	 Colon polyps	 Pancreatitis
 Jaundice	 Colon cancer	 Hiatal hernia
 Liver problems	 Diverticulitis	 Vomiting blood
 Hep A, B, or C	 Colitis	 Blood in stool	
OPERATIONS OR SURGERIES	
Please list all past operations, including cataract surgery, what type of surgery it was and when it was done	
TYPE	DATE	

		

		
		
PREVIOUS COLONOSCOPY	 YES	 NO		
PREVIOUS EGD	 YES	 NO		

Major Medical Illnesses	
Date	Place	Doctor	

			
			
HAVE YOU HAD A BLOOD TRANSFUSION	DATE	
□ Yes	□ No		
FAMILY HISTORY
Please list any diseases which tend to “run in your family” especially high blood press ure, diabetes, heart disease, cancer, gout, asthma, stomach ulcers, arthritis, allergies, epilepsy, tuberculosis, cystic fibrosis, muscle disease, stroke or thyroid dise ase.	
Marital Status	
□ Single	□ Married	□ Separated	□ Divorced	□ Widowed	□ Other	
Father’s History	

Is your Father?	□ Alive – Age  		□ Deceased – Age  	 What types of health problems if any did he have?	
Mother’s History	
Is your Mother?	□ Alive – Age  		□ Deceased – Age  	 What types of health problems if any did she have?	
Do you have any brothers?	
How many?	□ Alive – Ages  		□ Deceased – Ages  	 What types of health problems do/did they have?	
Do you have any sisters?	
How many?	□ Alive – Ages  		□ Deceased – Ages  	 What types of health problems do/did they have?	
If you served in the military:	
Were you ill while in the military?	□ Yes	□ No	What was the nature of the illness? Did you serve overseas?	□ Yes	□ No	If yes, where & when?	
Occupation	
Current employment status:	□ Disabled	□ Part time	□ Full time	□ Retired	□ Self-employed	□ Other

Occupation: 		
HABITS	

Have you ever smoked cigarettes regularly?	□ Yes	 □ No	If yes, how many packs per day? (avg) How many years?	Are you still smoking? □ Yes		□ No	If no, when did you stop?	
Do you use snuff or chewing tobacco?	□ Yes	□ No	Do you drink alcohol?	□ Yes	□ No	

How many beers daily?	How many years? How many mixed drinks or glasses of wine daily?	How many years?	
Do you have any drug, nicotine or alcohol habits which concern you?	□ Yes	□ No	
Do you regularly use sleeping pills, tranquilizers, or pain killers?	□ Yes	□ No

If yes, which ones?	

Do you currently use marijuana, cocaine or other “recreational” drugs?	□ Yes	□ No	
ANIMAL CONTACT	

Please list all pets or any other animals which you may have been in contact with in the past year:	
TRAVEL	

If you have traveled out of the Amarillo area in the past year, please list the places where you have been :	
IMMUNIZATIONS	

Hepatitis A                                               Flu                                                          Tetanus                                        Hepatitis B                                               Pneumovax                                            Other                                            TB skin test:  Result                                              When                                          Doctor                                         	
PLEASE LIST ALL MEDICATIONS THAT YOU ARE CURRENTLY TAKING	
Name	Dose	How often	Dr. prescribing	How long	

					

					

					

					
Non-Prescription (over the counter) medications including vitamins, health food or herbal products	
Name	Dose	How often	Dr. prescribing	How long	

					
Allergies to Medications and Reactions
Please list any medications or products you have taken which cause a true allergic reaction
(hives, itching, rash, or difficulty breathing)	
Medication	Reaction	

		

Food Allergies/Intolerances and Reactions	
Food	Reaction	

REVIEW OF SYSTEMS	
Please check any of the following symptoms or problems you are currently experiencing.  If the problem
has been resolved, leave it blank.  If you are unsure, place a question mark (?) by the medical issue.	
General

□ Weight loss

□ Weight gain

□ Fatigue

□ Fever

□ Night sweats

Do you eat a special diet? 	□Yes □No

Do you exercise regularly?   □Yes □No	Skin

□ Recent change in hair distribution

□ Changes in skin color

□ Itching

□ Rash

□ Hair loss

□ Other 		Head/Ear/Eyes/Nose/Throat

□ Diplopia (double vision)

□ Glaucoma

□ Hearing loss

□ Nose bleeds

□ Sore throat

□ Other 		
Neck

□ Neck mass

□ Neck pain

□ Neck stiffness

□ Swollen glands

□ Other 		Respiratory

□ Cough

□ History of Tuberculosis

□ Shortness of breath

□ Wheezing

□ Other 		Breast/GYN

□ Breast discharge

□ Breast swelling	□ Breast mass

□ Breast tenderness

□ Menses:Last one? 	

□ # Miscarriage  	

□ Other 		
Cardiovascular

□ Chest pain

□ Edema (swelling) 	

□ Fast/Irregular heartbeat

□ Orthopnea (trouble breathing while lying down)
□ Other 		Gastrointestinal

□ Abdominal pain

□ Nausea

□ Vomiting

□ Constipation/Diarrhea

□ Reflux

□ Other 		Genitourinary

□ Blood in urine

□ Dysuria (pain with urination)

□ Frequency of urination

□ Discharge

□ Nocturia (excessive urination at  night)

□ History of malignancy (cancer)

□ Other 		
Musculoskeletal

□ Arthritis

□ Back pain

□ Joint pain

□ Other 		Neurological

□ Headaches

□ Seizures

□ Strokes

□ Other 		Psychological

□ Anxiety

□ Depression

□ Insomnia

□ Other 		
Endocrine

□ Cold intolerance

□ Heat intolerance

□ Thyroid problems

□ Other 		Hematological

□ Anemia

□ Easy bleeding

□ Easy bruising

□ Other 		Other	

Signature: 	Date: 	

Reviewed by Physician:  	_	\\ade-sha res \JJ sers\m faulkner\ADCF0R MS \GI