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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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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 |
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Ulcerative Colitis
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Crohn's Disease
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Irritable Bowel Syndrome
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Heartburn or Reflux, since when?_______
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Hepatitis __A or ___B or ___C
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Other Liver Disease
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Gastroparesis
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Ulcer Disease what type?
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Pancreatitis
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Anemia
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Eating Disorder(Anorexia or Bulimia)
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Barrett's Esophagus
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YOUR OWN PAST MEDICAL
HISTORY |
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High Blood Pressure |
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Atrial Fribillation |
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Diabetes |
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On Coumadin or Plavix
for Anticoagulation |
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High Cholesterol |
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Bleeding disorder |
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Heart Disease |
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Depression or
psychiatric disorder |
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Angioplasty when?_______ |
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Kidney Disease (____check if on dialysis) |
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Joint Disease or
Arthritis |
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History of stroke |
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Thyroid Disease |
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Asthma or breathing
disorder |
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Sleep Apnea
Are you using CPAP?
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Cancer:
Colon __ Breast:__
Prostrate:__ Other:___ |
List
all additional important
History or symptoms to help
your Doctor:
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YOUR OWN PAST PROCEDURE HISTORY |
Check All that apply.
List the dates and other
information below. |
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Previous Upper Endoscopy, when________
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Previous ERCP, when_______
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Previous Colonoscopy, when________
Any Polyps? ___yes or ___no
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Requires Antiobiotics for procedures
____yes or ____no
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Other Procedures (check
here and list below)
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List
Other Details below: |
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YOUR OWN PAST ANESTHESIA HISTORY |
Check All that apply.
List the dates and other
information below. |
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No Problems in the past
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Sleep Apnea
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Allergy to eggs\sulfites\soybeans (circle if apply)
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Use Home Oxygen
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Bleeding after surgery or dental work
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Dentures
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Family History of Anesthesia problems
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Family History of Malignant Hyperthermia
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Height in inches________
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Weight in pounds_______
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List
any additional Anesthesia details or problems with Anesthesia below: |
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YOUR OWN PAST SURGICAL
HISTORY |
Check All that apply.
List the dates and other
information below. |
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Appendectomy |
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Gallbladder surgery |
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Hernia surgery |
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Gastric \ Stomach
surgery |
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C-section |
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Orthopedic Surgery (List
date below if in last 6
months) |
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Hysterectomy |
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Heart Bypass Surgery (CABG) |
List
Other Surgeries below: |
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ALLERGIES |
List Allergies to any
medications, and include
type of reaction and date
of allergy:
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None |
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Latex |
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Iodine |
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Eggs |
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Penicillin |
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Sulfa |
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Sulfites/Soybeans |
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Surgical Tape |
List any other Allergies |
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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 |
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Check Any Medications
that You are taking: |
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Aspirin, Circle Dose
(81mg or 325mg) |
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Over-the-counter Arthritis medicine |
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Birth Control Pills
Name of Pills: |
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Vitamins or Herbal
Supplements
List Names below: |
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REVIEW OF
SYSTEMS:
FAMILY HISTORY |
Indicate if there is a family history of: |
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Obesity
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Lung disease, Asthma, or Emphysema
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Diabetes
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Kidney disease
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High blood pressure
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Bleeding tendency or blood disorder
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Heart disease
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Breast cancer
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High Cholesterol
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Colon cancer
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Osteoporosis
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Colon Polyps
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Endocrine or metabolic disorders
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Stomach Cancer
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Esophageal Cancer
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Pancreatic Cancer
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Other
Cancer (List details below) |
Please give details as to which family members in the space below:
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REVIEW OF
SYSTEMS:
SOCIAL HISTORY |
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Never Smoked |
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Smoke -- Packs/day? |
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Years Smoking: |
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Quit Smoking in: |
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Don't Drink Alcohol |
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Drink Alcohol
How much per week: |
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Current Job: |
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I am exposed to Chemicals
or Fumes at work: |
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REVIEW OF
SYSTEMS:
IMMUNIZATION HISTORY |
Check all that apply
with dates they were given:
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Hepatitis A
date: |
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Hepatitis B
date: |
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Influenza (Flu
Shot)
date: |
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Measles
date: |
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Pheumovax (Pneumonia)
date: |
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Rubella
date: |
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Tetanus
(TD)
date: |
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Varicella (chicken
pox)
date: |
HIPPA (PATIENT PRIVACY) |
You may reveal results to:
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My Spouse, Significant other, or Family who is(are):
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You may reveal results to me alone. |
REVIEW OF
SYSTEMS: CONSTITUTIONAL |
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Anorexia |
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Fatigue |
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Fever |
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Weight Gain |
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Insomnia |
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Night
Sweats |
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Weight
Loss |
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REVIEW OF
SYSTEMS: HEAD |
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Head Trauma |
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Headaches |
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Migraine
Headaches |
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Seizures |
REVIEW OF
SYSTEMS: EYES |
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Cataract Surgery : R__ L__ Both__
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Dryness
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Double vision
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Glacoma
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Eye pain
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Blurred vision
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Diminished vision : R__ L__ Both__
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REVIEW OF
SYSTEMS: ENT |
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Dentures : Full___ Lower Plate___ Upper Plate___ Bridge___
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Dry mouth |
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hearing loss
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hoarseness
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nose bleeds
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REVIEW OF
SYSTEMS: C ARDIOVASCULAR |
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Shortness of Breath at rest
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Palpitations
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tachycardia
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lightheadedness
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dizziness
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edema (swelling of legs)
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chest pain
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angina
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Detailed Cardiac (Heart) History |
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Stress Test : When?_______ and Result?_
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Pacemaker
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Catherization : When?_______ and Result?_
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Defibrillator
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Echocardiogram :
When?_______ and Result?_
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tachycardia
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REVIEW OF SYSTE MS:
RESPIRATORY |
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History of TB
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Wears Oxygen(O2) night only
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Wears Oxygen(O2) constantly
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Exertional shortness of breath
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Shortness of breath at rest
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Rib pain
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Cough with mucus
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Cough with
no mucus |
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Wheezing
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Sleep Apnea
: Uses CPAP ____ -or- Does not use CPAP____
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Hemoptysis (coughing blood)
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DETAILED RESPIRATORY (LUNG) HISTORY |
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Asthma |
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Sacrcoidosis |
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COPD or Emphysema |
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History of Pulmonary
Embolus |
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Daily inhaler use |
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History of Steroid use
for breathing |
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Do you use Oxygen at
home? |
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Admitted to hospital for
Asthma or COPD |
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History of Intubation |
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Wake up from snoring /
Sleep Apnea |
REVIEW OF
SYSTEMS:
GASTROINTESTINAL HISTORY |
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Abdominal Pain : Where:
How long/often?
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Belching |
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Bloating |
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Change in Bowel habits |
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Feeling
of incomplete passage of bowels |
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Constipation |
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Diarrhea |
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Dyspepsia |
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Dysphagia |
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Early satiety (feel full quickly) |
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Fatty food intolerance |
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Fecal incontinence (lose control of your bowels) |
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Food intolerance (or allergies)
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Heartburn |
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Melena (black stools) |
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Post prandial fullness (feel full after meals) |
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Mucus discharge (from the rectum) |
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Nausea |
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Vomiting |
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Rectal bleeding |
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Rectal Pain |
Please add Details below: |
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REVIEW OF SYSTE MS:
HEMATOLOGIC/LYMPHATIC |
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History of : ____Leukemia or ___Myelodysplastic Syndrome |
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Easy bleeding |
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Easy bruising |
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Weight loss |
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Lymphadenopathy (swollen glands) |
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Night sweats |
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Pallor (pale) |
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Clotting Disorder |
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Bleeding Disorder |
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REVIEW OF SYSTE MS:
RENAL |
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Anemia which requires Procrit shots
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Being on Renal Dialysis
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Kidney Stones
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Polycystic Kidney Disease
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Have had Many Urine Infections
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Protienuria
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Chronic Renal Insuffiency (poor kidney function)
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REVIEW OF SYSTE MS:
ENDOCRINE |
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Change of Appetite : ___Increased or ___Decreased |
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Tremors |
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Blurred vision |
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Changes in
Hair texture |
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Hypoglycemia |
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Cold sensation (always feel cold) |
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Hypothyroidism |
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Hyperthyroidism |
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Excessive sweats |
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Impotence |
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Weakness |
REVIEW OF SYSTE MS:
NEUROLOGICAL |
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Alzieheimers Disease
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Ataxia (trouble with balance)
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Loss of Memory
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Dizziness |
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Headaches
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Hyperthyroidism
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Neuropathy (loss of feeling hands/feet)
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Numbness
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History of Seizures
: Last one was when?
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Weakness
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History of a TIA
: When?
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History of a Stroke
: When?
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Impotence |
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REVIEW OF SYSTE MS:
PSYCHIATRIC |
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Agitation
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Anorexia Nervosa
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Bulimia
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Anxiety
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Bi-Polar Disease
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Delusions
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Depression
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Manic Depression
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Disorientation |
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History of Suicide Attempts
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Last one when?_
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Suicidal Ideation
(Thoughts of Suicide)
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Insomnia (trouble sleeping)
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REVIEW OF SYSTE MS:
GENITOURINARY (Bladder) |
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Abnormal Menses (periods)
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Difficulty voiding/going your urine
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Dysuria
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Urine Frequency
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Hematuria (Blood in the urine)
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Hesitancy (trouble going)
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Leakage (of urine)
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Nocturia (going at night)
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Impotence (loss of erection)
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REVIEW OF SYSTE MS:
MUSCULOSKELETAL |
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Muscle Aching
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Neck pain
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Lower back pain
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Morning Stiffness |
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Joint pain |
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Joint Swelling
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Decreased range of
Motion of arms and legs |
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Radicular Pain (pain shooting down leg or arm)
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Knee Replacement
: Right____, Left____, or
Both ____
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Hip Replacement
:
Right____, Left____, or Both ____
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REVIEW OF
SYSTEMS: ALLERGIC
/ IMMUNOLOGIC |
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History of skin testing |
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Seasonal Allergies |
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Food Allergies
- List: |
REVIEW OF SYSTE MS:
SKIN |
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History of Basal cell cancer
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History of Melanoma
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Chronic skin rash
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Acne
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Alopecia
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Dry skin
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Hair loss
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Ulceration (of the skin)
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Easy Bruising habits
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OTHER |
List any other important
information not included
above about your health that would help the
Doctor: |
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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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Copyright © 2005-2010 Gastroenterology Consultants of South Jersey, P.C. All Rights Reserved.
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