Etowah Associates 1026 Goodyear Ave, Suite 201  Gadsden, AL 35904 Tel (256) 467-4477  Fax (256) 467-4830 Vipul Amin, M.D.

Name: ______Date of Birth: ______Age______Referring Physician: ______CHIEF COMPLAINT (describe in your own words the main reason you are seeing the doctor today): ______

MARK ALL SYSTEMS OR CONDITIONS THAT YOU CURRENTLY HAVE GASTROINTESTINAL Mark all symptoms or conditions that you CURRENTLY have:   Abdominal Swelling  Blood  Belching   Food / Milk Intolerance   Black Stool   Get Full Quickly at Meals  Painful Swallowing  Use  Vomiting  Change in Bowel Habits  Difficulty Swallowing  Blood in Stool   Pain with Bowel Movement  / Flatulence   NONE Have you had any of these procedures?  :  Yes Year: ______/ Physician: ______ No  Upper Endoscopy: Yes Year: ______/ Physician: ______ No  CT scan of (past 6 months):  Yes  No  Ultrasound of abdomen (past 6 months):  Yes  NO MUSCULOSKELETAL RESPIRATORY GENERAL  Physical Disability  Chronic  Lack of Appetite  Joint stiffness  Difficulty  Tiredness  Back pain  Wheezing  Night Sweats  NONE  NONE  Fever  Weight loss (over 10lbs) CARDIOVASCULAR BREAST  NONE  Fainting/Blacking out  Breast Pain  Swelling of Hands or Feet  Breast Mass HEENT  Chest pain  NONE  Wear glasses  Leg cramping  Wear contacts  Irregular heartbeats PYSHIATRIC  Hoarseness  NONE  Suicidal Thoughts  Decreased Hearing  Anxiety  Headache NEUROLOGICAL  Depression  NONE  Dizziness  Fainting OB/GYN GENITOURINARY  Loss of Consciousness  Menstrual abnormality  Change in urinary stream  Weakness in Extremities Are you currently pregnant?  Blood in urine  Seizure Yes No  Difficulty urine  Difficult Speech Last menstrual period   NONE date: ______ NONE ENDOCRINOLOGY DERMATOLOGY/SKIN  Cold Intolerance  Rashes  Excessive thirst  Itching  Heat intolerance  NONE  Change of appetite  Frequent Urination  NONE