Health Questionnaire

Please fill out the form completely, print, sign and remember to bring it to your office appointment Name (Last, First, MI): Today’s date: FAMILY HISTORY: Medical problems in your blood relatives: Please mark the appropriate space with M or F if that condition affected your mother or father, B or S if it affected your brother or a sister, C for child and GP for a grandparent:

Gallstones Ulcers Diabetes Arthritis Celiac disease (Gluten allergy) Colon polyps Colon cancer Colitis/ Crohn’s disease Irritable Bowel Syndrome Hemochromatosis (iron storage disease) Hepatitis Other liver diseases: What type: Heart disease High blood pressure Cancer: What type Depression Genetic diseases: What type

YOUR HEALTH HISTORY: Have you ever had any of these medical problems: Colon polyps Colon Cancer Ulcerative colitis Crohn’s Gallstones Diverticulitis Celiac disease (Gluten allergy) Ulcers Problems with excessive bleeding Hepatitis Jaundice Other liver Problems: Pancreatitis Diabetes High blood pressure Heart attacks Rheumatic fever Breathing difficulty Tuberculosis Sleep apnea Depression Arthritis Cancer: What type: Kidney stones Thyroid problems Stroke Infections: What type: Are you on Aspirin or other blood thinners? Which one: HAVE YOU HAD ANY SURGERIES:

Date What was done

HAVE YOU BEEN IMMUNIZED AGAINST ANY OF THE FOLLOWING: Hepatitis A Hepatitis B Tetanus Mumps Flu shot

MEDICATIONS YOU ARE TAKING: (Include vitamins, herbs and other over-the-counter products):

Name of medication Strength How often taken Reason taken

MEDICATIONS YOU ARE ALLERGIC TO: I am not aware of any drug allergies.

Name of medication When did the reaction occur? What was the reaction?

PHARMACY INFORMATION:

NAME OF THE PHARMACY YOU USE REGULARLY: CITY:

ADDRESS OR NEAREST CROSS STREET: PHONE:

HAVE YOU HAVE HAD ANY OF THE FOLLOWING TESTS: When Results Ultrasound CAT scan of the abdomen Colonoscopy Endoscopy of the stomach (EGD)

SOCIAL HISTORY:

Place of Birth (include country if you were not born in the US): Current Occupation: Have you been exposed to hazardous material? choose Were you a smoker ever? choose If Yes: Age began Age quit Number of packs per day Are you currently smoking: choose Do you drink alcohol? choose If Yes: What kind? How often? Do you drink sodas or coffee? Daily? No If not daily then how often? How many per day? Do you exercise: choose If Yes: How often: What type of exercise:

REVIEW OF SYMPTOMS: (Check where applicable for recent occurrence)

Head and Neck: Digestive System: Female Reproductive System: Frequent headaches Problem swallowing Last menstrual period: Neck pain Heartburn Last GYN exam: Neck lumps Belching Are you currently pregnant Eyes : Nausea Do you have irregular periods Change in vision Vomiting Heavy menstrual flow Double vision Vomiting blood Vaginal discharge Eye pain or redness Bloating Painful intercourse See fixed spots Black stools Breast lumps Ears: Blood in the stools. Skin: Hearing difficulty Constipation Easy bruising Ringing ears Diarrhea Change in color Earache Diverticulosis Itching or burning Discharge from ears Hemorrhoids Neurological: Mouth: Loss of appetite History of seizures Pain on chewing Weight loss Easy fainting Bleeding gums Blood transfusion Tremors Sore gums or mouth Use of street drugs Numbness in extremities Contact with hepatitis Weakness in extremities

(CONTINUED) Nose and throat: Frequent nosebleeds Jaundice Backache Change in voice Extremities: Mood: Nasal congestion Swelling or redness of the joints Difficulty relaxing Respiratory: Rash over the legs Feel excessively stressed Wheezing Leg cramps Suicidal ideas Coughing phlegm Urinary: Desire psychiatric help Coughing blood Frequent urination at night Recent colds Burning on urination Cardiovascular: Urgency to urinate High blood pressure Blood in the urine Irregular heartbeats Difficulty starting urine stream Heart attacks Male Reproductive System: Chest pain Thin urine stream Shortness of breath Lumps or pain in the testicle Leg swelling Prostate problems ______Signature