Date
Name
Primary Care Doctor.
(such as Family Practice, lnternal Medicine, Ob/Gyn)
I
City/State
Referring Doctor
City/State
PLEASE READ COMPLETELY AND CAREFULLY
Present Medical Historv: List the main complaints which lead to this office visit
Check SIGNIFICANT complaints below:
n Rectalbleeding: n on toilet paper n
bowl I
I
n with clots
I
I
r
Rectal
Rectal
pain:
bright
red
n black, tarry
dark red
into toilet
mixed with
stool
n found on card test (not visible)
n constant
n increasing
n with bowel movements
!
sporadic
n
Rectal itching
swelling r
r
hemorrhoids that come
out
Incontinence (soiling/accidents)
Other rectal con@rns
n Abdominal pain
n Nausea
n Abdominalcramping I Vomiting
I Abdominalbloating
I
I
Weight change (past 6 months) n
Other Abdominal complaints
Vomiting
loss
I
n Stomach/Duodenalulcer
blood
n gain (
lndigestion (frequenUsevere)
I
Esophageal reflux (hiatal hernia)
pounds)
r
Loss of appetite
irregular bowel habits
n Recent change in bowel habits
n Diarrhea:
n loose n watery ! mucous n bloody n How long?
n Constipation: n infrequent stools n straining/difficultyn firm stools I How long?
Stools per day n1 a2 tr3 tr4
!5
n Laxative use (frequent)
n stool softeners (Surfax,
nO or more or Stools per week n6 15 tr4 n3 n2 n1 rless than one
Colace)
n stimulants (Ex-Lax, Dulcolax,
Other laxatives
How often used?
Diet n high fiber (more
n "natural" (herbaltea, senna,
cascara)
Doxidan) n fiber (Metamucil, Citracel, Konsyl)
I
FiberCon
How long used?
n high fiber cereal (Fiber One, All Bran)
I other cereals n diabetic diet
n avoid nuts, seeds, popcorn, etc.
I Coffee n Tea
I Coca Cola n Carbonated beverages n Chocolate
Water n less than 4 olasses/dav n 4-8
tr more than 8
Current
DRUG
ALLERGIES:
n penicillin
than 6 fruits/vegetables per day)
n No Known Drug Allergies
I sulfa
n Allergy to lV dye
Other druo alleroi
Last revised:11113197
I
(lodine)
localanesthesia (Novocain/Lidocaine)
tr "mycins'
n codeine
Date
Name
adopted
Familv Historv
I
illother
Father
age_
age_
deceased-
living
n living
living_
# sisters living# brothers
n deceased Cause
I deceased Cause
Cause
Cause
deceased
Has any relative had:
polyps: n parent n brother/sister
I Colon Gancer: n parent n brother/sister
I Ulcerative colitis: n parent r brotherlsister
I Crohn's disease: I parent I brother/sister
n Colon
Other conditions within your family:
r
I
I
I
Asthma
Heart attack
Ovarian cancer
Other family diseases.
Lung
€n€r
n high blood pressure
n Breast cancer
colitis
n analfissure/ulcer
Disease
Crohn's
r
hemorrhoids
I
n grandparenVaunVuncle/cousin
n grandparenUaunVunclelcousin
I
grandparenUaunVuncle/cousin
n grandparenUaunUuncle/cousin
n bleeding disorders n Diabetes
n stroke
n dementia I
n lymphoma I leukemia n
Past Medical Historv
Have yq had prior diagnosis of:
I colon cancer
n colon polyps
I
I child
I child
I child
n child
Ulcerative
seizure
TB
n diverticulitis
n spastic colon (irritable bowel)
u rectal abscess
surgery: I Hemorrhoidectomy n Analfissure/ulcer n Drain rectal abscess
Colon resection n Appendectomy n Gallbladder I Exploratory
Previous
r
I stomach surgery (l
I
resection for cancer/ulcers
n bypass)
I
Open
Other
heart
I
heart
valve
bowel obstruction
n tubal ligation
n reduction) I Prostate (n benign
Hysterectomy (remaining ovaries: nnone none n
n Breast (n cancer n benign n implants
I
both)
I angioplasty I
I
I
C-section
cancer)
vascular bypass
List your current medications (lnclude blood thinners and aspirin, HERBAUNATURAL)
Doctor
Times per day
Medication/Dose
SocialHistorv
I smoking I chewing tobacco n snutf n alcohol use
n separated n divorced
I single r married
Occupation
n retired
I
drug abuse
n widodwidower
Date
Name
Systems Review (Other SIGNIFICANT concerns)
General
I
I
good health
declining
health
n fever
r
fatigue
I
blurred/double vision
Ophthalmologist
Eyes
lglasses/contacts n
glaucoma
Ears, Nose, ilouth & Throat
I
I
!
cataracts I
cataract
surgery
ENT Doctor
earaches/drainage
n hearing aid
n mouth sores
sore throat/voice change
I
hearing loss/ringing
n chronic sinusitis
n bleeding gums
D nose bleeds
n bad breath/taste
swollen neck glands
Cardiolooist
Heart & Vascular
nchest pain/angina
I
I
n palpitations/heart racing n
wake up short of breath
swelling I
nankle
shortness of breath
walking n foot pain while
leg pain with
sleeping
Pulmonary Doctor
Lungs
n coughing blood ldifficulty
nchronic cough
Genitourinary
Ob/Gyn
Urologist
r
n burning with urination
n urinary incontinence
nnormal periods
Last menstrual period:
lllusculoskeletal
narthritis
I
n
psoriasis
r
breast lump
blood in
urine
n difficulty with urination
r
n impotence
testicular pain
post menopause
period I
I current weeks ago !1 n2 13 n4 or more !
I
irregular
I
muscular pain/weakness
Skin/Breast
n asthma/wheezing
breathing
back pain/disk
I kidney stone
r painful intercourse
possibly pregnant
disease
Dermatologist
n change
n chronic rash
n
I
breast pain
Neu rolog ist-Neu
Neurological
n chronic headaches I seizures tr
in hair/nails n varicose veins
nipple discharge
rosu rgeon
tremors
n stroke
n
head injury
I
insomnia
Psychiatric
n
memory loss/confusion
r anxiety I
depression
Endocrine
n Thyroid disease
n
Diabetes
I
Cushing's disease
Hematolog ic/Lymphatic
I Anemia I
Allergy
Oncologist
previous blood transfusions
free bleeding
I
Allergist
I
food allergy
n difficulty walking
I
environmental allergy (hay fever, dogs/cats, pollen etc.)
Other
Thank you
n AIDS