Patient Interview Form

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1 Patient Interview Form Patient Information First Name: Date Of Birth: Last Name: Age: Please check one as your preferred for communications Personal: Work: Race Select one or more White Unknown Black or African American Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Ethnicity Hispanic or Latino Not Hispanic or Latino Sex Male Female Other Preferred Language English Spanish; Castilian Contact Preference Portal message Home Phone Mobile phone Work phone Immunizations When: Hep A When: Hep B

2 Diagnostic Studies/Tests In the past 12 months I have had xray tests In the past 12 months I have had Lab tests Colonoscopy EGD- Esophagogastroduodenoscopy Previous Procedures Gastrointestinal Appendectomy Ulcer surgery Hemorrhoidectomy Hernia repair Inguinal Herniorraphy Adhesion ERCP Gallbladder Anal Fissure removed/cholecystectomy Weight Loss : Gastric Band/Lap Band Endoscopic Ultrasound (EUS) Weight Loss : Gastric By-Pass Liver Biopsy Large Intestine/Colon Small Bowel Capsule Cardiovasular Pulmonary Carotid Stent Left Aortic Aneurysm Repair Coronary Artery Cath Coronary artery bypass surgery Heart valve replacement Pacemaker OB/GYN Hysterectomy Tubal Ligation Breast Aspiration/Biopsy Breast Removal/Mastectomy Ovary Removed/Oophorectomy ENT Tonsillectomy Sinus Cardiac Ablation Defibrillator Endocrinology Thyroidectomy Thyroid Biopsy Parathyroidectomy Urology Prostatectomy Bladder Resection Prostate Nephrectomy Orthopedic and Neurological Other Not Listed Knee ( Right) Shoulder Knee ( Left ) Hand Bladder Lift Hip Replacement (Right) Craniotomy (Brain ) Bladder (other) Hip Replacement ( Left ) Spinal #1: #2: #3:

3 Past or Present Medical Conditions Gastrointestinal Hepatitis B Hepatitis C Cirrhosis Liver disease H. Pylori Pancreatitis Gallstones Gastric Cancer Colon Cancer GERD Colitis Celiac IBS Heartburn Diverticulitis Ulcer Crohn's Disease Peptic ulcer disease Barrett's esophagus Ulcerative Colitis Bile Duct Cancer Esophageal Cancer Lactose/milk intolerance Pancreatic Cancer Cardiovascular High blood pressure Angina High cholesterol Congestive Heart Failure High triglycerides Atrial Fibrillation Heart attack Other heart rhythm disturbance Respiratory/Lung Chronic bronchitis Pulmonary Edema Emphysema Asthma Sleep apnea Tuberculosis C.O.P.D. Neurology Migraines Stroke TIA Seizures Neuropathy Alzheimer Endocrine Osteoporosis Osteopenia Diabetes Mellitus Hypothyroidism Thyroid - other Hyperthyroidism Genitourinary Kidney stones Kidney failure STD Eye Glaucoma Cataracts Conjunctivitis Macular Degeneration Rheumatology Arthritis Autoimmune Disease Psychology Anxiety disorder Depression Panic attacks Eating Disorder Hematology Anemia Blood disorder HIV Oncology Breast Cancer Prosate Cancer Renal Cell Carcinoma Pharmacy Name Address Phone Current Medications Name Dose How taken?

4 Allergies Patient has no known allergies Patient has no known drug allergies aspirin Codeine Demerol Fentanyl Flagyl Iodine Levaquin Cipro morphine Penicillins Sulfa Versed Latex Eggs Shellfish Nuts midazolam Social History Occupation: Number of Children: Marital Status Single Married Divorced Separated Widowed Civil Union Unknown Other Alcohol Less than 7 drinks per week More than 7 drinks per week I quit using alcohol Drug Use I have used recreational drugs in the past I am currently using recreational drugs I have been treated for substance abuse Exercise Exercise 1-2 days per week Exercise 3 days or more per week Caffeine Daily consumption of beverages containing caffeine Rarely consume beverages containing caffiene Tobacco Smoking Status Current every day smoker Smoker, current status unknown Current some day smoker Light tobacco smoker Former smoker Heavy tobacco smoker Never smoker Unknown if ever smoked Type Cigar Cigarettes

5 Family Medical History No knowledge of family history No family history of Colon Polyp Family history of Colon Cancer Health Status Healthy Ill In Remission Deceased/At Age Diagnoses Colon cancer Colon polyp Ulcerative Colitis Crohn's disease Liver disease Ovarian cancer Uterine cancer Kidney Cancer Stomach cancer Bladder cancer Pancreatic cancer

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