Patient Interview Form

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1 Patient Interview Form Patient Information First Name: Date Of Birth: Family Doctor: Last Name: Age: Referred By: Chief Complaint: For how long: Character of pain: Sharp Dull Burning Aching Location: Lower Upper Center Right Left abdominal abdominal side side Does pain radiate to any part of the body: No To: Frequency: Duration: Does pain change with: Eating: Worse Better No Change Antacids: Worse Better No Change Bowel Movements: Worse Better No Change Does Pain wake you from sleep: No Heartburn: No Better with treatment Intermittent Progressive Difficulty swallowing: No Solids Liquids Both Painful swallowing: No Solids Liquids Both Any: Nausea Vomiting Excessive Gas Bloating Belching Appetite: Up Down No Change Weight: Up Down No Change lbs. in days Bowel movements: Regular Constipation Diarrhea Alternating Frequency: Any blood: No If yes, is blood mixed with: Stool Toilet paper only Bleeding painful: No Bleeding associated with: Weakness Lightheaded Cramps

2 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 Vietnamese Contact Preference Letter Cell Phone Home Phone All above Reminder Preference I would like to receive preventive care and follow up care reminders. No Consent to Share Data I consent to having my medical and demographic information shared with other health care entities. No

3 Consent to Import Medication History I consent to obtaining a history of my medications purchased at pharmacies. No Pharmacy Name Address Phone Allergies Patient has no known allergies Patient has no known drug allergies Current Medications Name Dose How taken? Immunizations Hep B Hep A Flu vaccine TB Screen PCV Social History Occupation: Number of Children: Marital Status Single Married Divorced Separated Widowed Civil Union Unknown Other Alcohol Type Quantity Number Frequency Beer Liquor Wine Caffeine

4 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 Started Quit Quantity Frequency Cigarettes Cigar Pipe Smokeless Drug Use Type Quantity Number Frequency Exercise Type Quantity Number Frequency Walking Cardio Running Other Family Medical History No knowledge of family history No family history of Colon cancer Polyps Diagnoses Hypertension Diabetes Mellitus Coronary Artery Disease Congestive heart failure Crohn's Disease Ulcerative Colitis Colon Cancer Rectal Cancer Stomach Cancer Esophageal Cancer Pancreatic Cancer Colon polyp(s)

5 Past or Present Medical Conditions Asthma-Mild Mitral valve prolapse Iron deficiency Anemia Hypercholesterolemia Asthma- Moderate CVA COPD Hypertension Asthma-Severe TIA Diabetes Mellitus Hyperthyroidism Congestive heart failure Myocardial infarction Gastric ulcer Hypothyroidism Coronary artery disease Anemia GERD Renal failure Migraines Neuropathy Osteoporosis Pneumonia Rheumatic Fever Rheumatoid arthritis Arthritis Seizures Sleep apnea Alzheimer's disease Dementia Depression Anxiety Deep vein thrombosis Diverticulosis Fatty liver- NAFLD Crohn's Disease Colon polyps Cirrhosis Hepatitis B Virus Hepatitis A Virus Hepatitis C Virus Ulcerative colitis Diagnostic Studies/Tests Colonoscopy EGD Flexsigmoidoscopy Bone density Mammogram Previous Procedures Hernia Repair Vasectomy Colon Resection Tonsillectomy Appendectomy Tubal Ligation C-Section Hemorrhoidectomy Gastric Band Hip Replacement D and C Gastric By-Pass Bunionectomy Exploratory Laparotomy/Laparoscopy Lithotripsy CABG Pacemaker Open Heart Surgery- Hysterectomy Back Surgery Knee replacement Laparoscopic Cholecystectomy Open Cholecystectomy Foot Surgery Prostate surgery Breast surgery Shoulder Surgery Carpal Tunnel surgery Transplant PTCA

6 Review Of Systems Cardiovascular chest pain irregular heart beat peripheral edema ENMT ear pain nose bleeds sore throat hearing loss hoarsness sinus Constitutional fatigue fever sweats weight gain weight loss chills Endocrine excessive thirst excessive urination Genitourinary decrease in urine flow frequent urinary infections frequent urination nocturia menses Hematologic/Lymphatic easy bruising prolonged bleeding palpable lymph nodes Integumentary allergies rashes Musculoskeletal back pain joint pain muscle weakness stiffness Neurological dizziness fainting frequent headaches migraine numbness or tingling seizures Psychiatric anxiety depression nervousness Respiratory asthma cough shortness of breath with exercise wheezing Eyes double vision loss of vision blurring vision Reviewed with Patient Parent Guardian Not Present Signature Signature Date

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