Health History Form - Gastroenterology Associates of New Jersey

HEALTH HISTORY FORM FOR GASTROENTEROLOGY ASSOCIATES OF NJ

Today’s Date

Patient’s Name

Age

Referred by

GASTROINTESTINAL DISORDERS/SYMPTOMS

Upper GI Explain any yes answers

Changes in appetite

Yes

No

Please explain

Early satlety (feeling of fullness)

Yes

No

Please explain

Difficulty swallowing

Yes

No

Please explain

Indigestion/gas/belching

Yes

No

Please explain

Nausea/vomiting

Yes

No

Please explain

Heartburn/regurgitation

Yes

No

Please explain

Stomach pain (before or after meals)

Yes

No

Please explain

Ulcers

Yes

No

Please explain

Gallbladder disease

Yes

No

Please explain

Liver disease (jaundice,hepatitis,cirrhosis)

Yes

No

Please explain

Pancreatitis

Yes

No

Please explain

Lower GI

Abdominal pain/cramping

Yes

No

Please explain

Gas/bloating

Yes

No

Please explain

Lactose intolerance

Yes

No

Please explain

Change in bowel habits

Yes

No

Please explain

Constipation

Yes

No

Please explain

Diarrhea

Yes

No

Please explain

Rectal bleeding/hemorrhoids

Yes

No

Please explain

Mucus in stools

Yes

No

Please explain

Fecal incontinence

Yes

No

Please explain

Inflammatory bowel disease

Yes

No

Please explain

Crohn’s/ulcerative colitis

Yes

No

Please explain

Celiac Disease

Yes

No

Please explain

Irritable bowel syndrome/spastic colon

Yes

No

Please explain

Diverticulosis/diverticulitis

Yes

No

Please explain

Colon Polyps

Yes

No

Please explain

Gastrointestinal cancer

Yes

No

Please explain

PREVIOUS GI TESTING (When and Where)

Blood tests

Stool tests

Abdominal x-rays or CAT scan

Upper GI series/barium swallow

Lower GI series/barium enema

Sigmoidoscopy

Colonoscopy

Upper Endoscopy

Gallbladder tests

OB HISTORY

# Full Term

#Miscarriages

#Abortions

LIST MEDICATIONS & DOSAGE:

No medications

List medications & dosage:

Do you have any allergies (including medication, food environmental, and reaction to previous blood transfusion)

Yes

No

Please describe:

Medical Conditions you have had and/or are being treated for: (i.e. heart disease, lung disease, hypertension, etc.) Continue on back if needed

SURGERIES/HOSPITALIZATIONS

Year/type

No Surgeries

Have you had any problems with anesthesia?

Yes

No

PERSONAL HABITS:

Tobacco

Yes

No

pk/day

Alcohol

Yes

No

oz/day/wk

Caffeine

Yes

No

cups/day

Recreational drugs

Yes

No

year started and drugs kind

Family History:

Mother

current or past medical conditions:

Father

Age

current or past medical conditions:

Sibling M/F

Age

current or past medical conditions:

Sibling M/F

Age

current or past medical conditions:

Sibling M/F

Age

medical conditions

Sibling M/F

Age

medical conditions

Sibling M/F

Age

medical conditions

Sibling M/F

Age

medical conditions

Indicate if your parents, brothers, sisters, and/or children have a history of:

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