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Gastroenterology Consultants of South Jersey
Amherst Commons, Building A, Suite 2
693 Main Street, Lumberton, New Jersey
Telephone: (609) 265-1700    Visit us Online: www.GCSJ.org

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MEDICAL HISTORY FORM

Patient Name: ______________________________________ Date of Birth (month/day/year): _____/_____/_____

Your answers on this form will help your Doctor understand your medical concerns and conditions better. If you are uncomfortable with any question, do not answer it. Best estimates are fine if you cannot remember specific details. Thank you!

Reasons for this Visit? _____________________________________________________________________________

Please check the boxes below if they apply to You in any of the History Sections below:

YOUR OWN PAST GASTROINTESTINAL (GI) HISTORY

 

Ulcerative Colitis

 

Crohn's Disease

 

Irritable Bowel Syndrome

 

Heartburn or Reflux, since when?_______

 

Hepatitis __A or ___B or ___C

 

Other Liver Disease

 

Gastroparesis

 

Ulcer Disease what type?

 

Pancreatitis

 

Anemia

 

Eating Disorder(Anorexia or Bulimia)

 

Barrett's Esophagus

 

YOUR OWN PAST MEDICAL HISTORY

 

High Blood Pressure

 

Atrial Fribillation

 

Diabetes

 

On Coumadin or Plavix for Anticoagulation

 

High Cholesterol

 

Bleeding disorder

 

Heart Disease

 

Depression or psychiatric disorder

 

Angioplasty when?_______

 

Kidney Disease (____check if on dialysis)

 

Joint Disease or Arthritis

 

History of stroke

 

Thyroid Disease

 

Asthma or breathing disorder

 

Sleep Apnea
         Are you using CPAP?

 

Cancer:
Colon __ Breast:__ Prostrate:__ Other:___

List all additional important History or symptoms to help your Doctor:

 

 

 

 

 

 

     

YOUR OWN PAST PROCEDURE HISTORY

Check All that apply. List the dates and other information below.

  

Previous Upper Endoscopy, when________

 

Previous ERCP,  when_______

 

Previous Colonoscopy, when________
             Any Polyps? ___yes or ___no

 

Requires Antiobiotics for procedures
              ____yes or ____no

 

Other Procedures (check here and list below)

List Other Details below:

 

 

 

 

 

YOUR OWN PAST ANESTHESIA HISTORY

Check All that apply. List the dates and other information below.

  

No Problems in the past

 

Sleep Apnea

 

Allergy to eggs\sulfites\soybeans (circle if apply)

 

Use Home Oxygen

 

Bleeding after surgery or dental work

 

Dentures

 

Family History of Anesthesia problems

 

Family History of Malignant Hyperthermia

  Height in inches________   Weight in pounds_______
List any additional Anesthesia details or problems with Anesthesia below:

 

 

 

 

 

YOUR OWN PAST SURGICAL HISTORY

Check All that apply. List the dates and other information below.

  

Appendectomy

 

Gallbladder surgery

 

Hernia surgery

 

Gastric \ Stomach surgery

 

C-section

 

Orthopedic Surgery (List date below if in last 6 months)

 

Hysterectomy

 

Heart Bypass Surgery (CABG)

List Other Surgeries below:

 

 

 

 

   

ALLERGIES

List Allergies to any medications, and include type of reaction and date of allergy:

 

None

 

Latex

 

Iodine

 

Eggs

 

Penicillin

 

Sulfa

 

Sulfites/Soybeans

 

Surgical Tape

List any other Allergies

 

 

 

         

MEDICATIONS
YOU MUST LIST THE DOSE OF YOUR MEDICINES

If you have a list of medicines with you, then you can write the list in the spaces below. 

NAME OF MEDICATION

DOSE & FREQUENCY

CONDITION

Example: Pepcid

20mg twice a day

Heartburn

     
       
     
     
     
     
     

Check Any Medications that You are taking:

 

Aspirin,  Circle Dose (81mg or 325mg)

 

Over-the-counter Arthritis medicine

 

Birth Control Pills
Name of Pills:

 

Vitamins or Herbal Supplements
List Names below:

  

   

   

REVIEW OF SYSTEMS: FAMILY HISTORY

Indicate if there is a family history of:

  

Obesity

 

Lung disease, Asthma, or Emphysema

 

Diabetes

 

Kidney disease

 

High blood pressure

 

Bleeding tendency or blood disorder

 

Heart disease

 

Breast cancer

 

High Cholesterol

 

Colon cancer

 

Osteoporosis

 

Colon Polyps

 

Endocrine or metabolic disorders

 

Stomach Cancer 

 

Esophageal Cancer

 

Pancreatic Cancer

  Other Cancer (List details below)
Please give details as to which family members in the space below:

 

 

        

REVIEW OF SYSTEMS: SOCIAL HISTORY

 

Never Smoked

 

Smoke -- Packs/day?

 

Years Smoking:

 

Quit Smoking in:

 

Don't Drink Alcohol

 

Drink Alcohol
How much per week:

 

Current Job:

 

I am exposed to Chemicals or Fumes at work:

   

   

REVIEW OF SYSTEMS: IMMUNIZATION HISTORY

Check all that apply with dates they were given:

 

Hepatitis A
date:

 

Hepatitis B
date:

 

Influenza (Flu Shot)
date:

 

Measles
date:

 

Pheumovax(Pneumonia)
date
:

 

Rubella
date:

 

Tetanus (TD)
date:

 

Varicella (chicken pox)
date:

      

HIPPA (PATIENT PRIVACY)

You may reveal results to:

 

My Spouse, Significant other, or Family who is(are):
   

  You may reveal results to me alone.

  

REVIEW OF SYSTEMS: CONSTITUTIONAL

 

Anorexia

 

Fatigue

  Fever
 

Weight Gain

 

Insomnia

  Night Sweats
  Weight Loss        

   

REVIEW OF SYSTEMS: HEAD

 

Head Trauma

  Headaches
  Migraine Headaches   Seizures

   

REVIEW OF SYSTEMS: EYES

 

Cataract Surgery : R__ L__ Both__

  Dryness
  Double vision   Glacoma
  Eye pain   Blurred vision
  Diminished vision : R__ L__ Both__    

 

REVIEW OF SYSTEMS: ENT

 

Dentures : Full___ Lower Plate___ Upper Plate___ Bridge___

  Dry mouth   hearing loss
  hoarseness   nose bleeds

 

REVIEW OF SYSTEMS: CARDIOVASCULAR

 

Shortness of Breath at rest

 

Palpitations

  tachycardia
  lightheadedness  

dizziness

  edema (swelling of legs)
  chest pain   angina    

Detailed Cardiac (Heart) History

  Stress Test : When?_______ and Result?_   Pacemaker
  Catherization : When?_______ and Result?_   Defibrillator
  Echocardiogram : When?_______ and Result?_   tachycardia

          

REVIEW OF SYSTEMS: RESPIRATORY

 

History of TB

 

Wears Oxygen(O2) night only

  Wears Oxygen(O2) constantly
 

Exertional shortness of breath

 

Shortness of breath at rest

  Rib pain
  Cough with mucus   Cough with no mucus   Wheezing
  Sleep Apnea : Uses CPAP ____  -or- Does not use CPAP____   Hemoptysis (coughing blood)

 

DETAILED RESPIRATORY (LUNG) HISTORY

 

Asthma

 

Sacrcoidosis

 

COPD or Emphysema

 

History of Pulmonary Embolus

 

Daily inhaler use

 

History of Steroid use for breathing

 

Do you use Oxygen at home?

 

Admitted to hospital for Asthma or COPD

 

History of Intubation

 

Wake up from snoring / Sleep Apnea

 

REVIEW OF SYSTEMS:
GASTROINTESTINAL HISTORY

 

Abdominal Pain : Where:                         How long/often?

 

Belching

 

Bloating

  Change in Bowel habits   Feeling of incomplete passage of bowels
 

Constipation

 

Diarrhea

 

Dyspepsia

 

Dysphagia

 

Early satiety (feel full quickly)

 

Fatty food intolerance

 

Fecal incontinence (lose control of your bowels)

 

Food intolerance (or allergies)

 

Heartburn

 

Melena (black stools)

 

Post prandial fullness (feel full after meals)

 

Mucus discharge (from the rectum)

 

Nausea

 

Vomiting

 

Rectal bleeding

 

Rectal Pain

Please add Details below:

 

 

 

 

REVIEW OF SYSTEMS: HEMATOLOGIC/LYMPHATIC

 

History of :  ____Leukemia or ___Myelodysplastic Syndrome

 

Easy bleeding

 

Easy bruising

  Weight loss
  Lymphadenopathy (swollen glands)   Night sweats    Pallor (pale)
  Clotting Disorder    Bleeding Disorder  

 

REVIEW OF SYSTEMS: RENAL

 

Anemia which requires Procrit shots

 

Being on Renal Dialysis

  Kidney Stones
  Polycystic Kidney Disease   Have had Many Urine Infections   Protienuria
  Chronic Renal Insuffiency (poor kidney function)  

 

REVIEW OF SYSTEMS: ENDOCRINE

  Change of Appetite :  ___Increased or ___Decreased   Tremors
 

Blurred vision

 

Changes in Hair texture

  Hypoglycemia
  Cold sensation (always feel cold)   Hypothyroidism   Hyperthyroidism
  Excessive sweats   Impotence   Weakness

 

REVIEW OF SYSTEMS: NEUROLOGICAL

  

Alzieheimers Disease

 

Ataxia (trouble with balance)

  Loss of Memory
  Dizziness   Headaches   Hyperthyroidism
  Neuropathy (loss of feeling hands/feet)   Numbness
  History of Seizures : Last one was when?   Weakness
  History of a TIA : When?   History of a Stroke : When?   Impotence
  

  

REVIEW OF SYSTEMS: PSYCHIATRIC

 

Agitation

 

Anorexia Nervosa

  Bulimia
  Anxiety   Bi-Polar Disease   Delusions
  Depression   Manic Depression   Disorientation
  History of Suicide Attempts :
Last one when?_
  Suicidal Ideation
(Thoughts of Suicide)
  Insomnia (trouble sleeping)

  

REVIEW OF SYSTEMS: GENITOURINARY (Bladder)

 

Abnormal Menses (periods)

 

Difficulty voiding/going your urine

  Dysuria
  Urine Frequency   Hematuria (Blood in the urine)   Hesitancy (trouble going)
  Leakage (of urine)   Nocturia (going at night)    Impotence (loss of erection)

 

REVIEW OF SYSTEMS: MUSCULOSKELETAL

 

Muscle Aching

 

Neck pain

   Lower back pain
  Morning Stiffness   Joint pain   Joint Swelling
  Decreased range of Motion of arms and legs  
  Radicular Pain (pain shooting down leg or arm)
  Knee Replacement : Right____, Left____, or Both ____
  Hip Replacement : Right____, Left____, or Both ____

  

REVIEW OF SYSTEMS: ALLERGIC / IMMUNOLOGIC

  History of skin testing   Seasonal Allergies
  Food Allergies - List:

 

REVIEW OF SYSTEMS: SKIN

 

History of Basal cell cancer

 

History of Melanoma

  Chronic skin rash
  Acne   Alopecia   Dry skin
  Hair loss   Ulceration (of the skin)   Easy Bruising habits

 

OTHER

List any other important information not included above about your health that would help the Doctor:

 

 

 

 

 

 

 

 

 

 

  

We also suggest you do this kind of History with a list of your Doctors (phone and fax numbers), Medications (with does and how often), allergies, major medical problems (with dates), major surgeries (with dates) for yourself on a piece of paper, or ideally on the computer, and keep this with you. This can help Doctors better take care of you if you are seen in an Emergency Room, or at a new Doctor visit.

Please for all future visits always bring
a List of your current Medicines
with the doses and how often taken.

Thank you very much for filling this out as it helps the Doctor take care of you better!
Reviewed by: _________________________________________________________ 
Date: _______/_______/______

Please Note:   We have two(2) locations.  All NEW patients will first be seen at Gastroenterology:

Gastroenterology Consultants of So. Jersey:
www.GCSJ.org
Amherst Commons, Building A, Suite 2
693 Main Street
Lumberton, New Jersey
Telephone: (609) 265-1700
Burlington County Endoscopy Center:
www.BCEndoscopyCenter.com
140 Mt. Holly Bypass, Unit 5
Lumberton, New Jersey
Telephone: (609) 267-1555

  

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