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PATIENT INFORMATION FORM
______________________________________________________________________________________________ Patient’s Name: __________________________________________ Date of Birth: ___________________________________ Address: _______________________________________________________________________________________________ Phone: Home: ___________________________________ Cell: ____________________________________________ Work: ___________________________________ Other: ___________________________________________ Referring Physician: __________________________________________ Telephone: __________________________________ Address: _______________________________________________________________________________________________ What are the main concerns that prompted your visit today? ______________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ ___________________________________________________________________ PERSONAL HISTORY 1. Previous Hospitalizations and/or Surgeries (List dates/types) _______________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 2. Other Medical Problems (Check all that apply) Anemia GI Problems High Cholesterol Pancreatitis Thyroid Disease Arthritis Gout Infections Phlebitis Ulcers Asthma Heart Attack Inflammatory Bowel Rashes Disease Unconscious Blood Transfusion Heart Disease Rheumatic Fever Kidney Disease Cancer Heart Murmur Seizures Kidney Stone Cystitis Hepatitis Stroke Obesity Diabetes High Blood Pressure TB Osteoporosis 3. Allergies (Drug, food, etc): __________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 4. Current Medications and Doses (including vitamins and over the counter medications): 1. ________________________ 4. ________________________ 7. _____________________ 2. ________________________ 5. ________________________ 8. _____________________ 3. ________________________ 6. ________________________ 9. _____________________ 5. List any other Physicians you are currently seeing: Name Location Reason ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ FAMILY HISTORY Father Mother Sibling Father Mother Sibling High Blood Pressure Pancreatic Cancer Heart Attack/ Stroke Esophageal Cancer Colon Cancer Gastric Cancer Breast Cancer Inflammatory Bowel Disease Other Cancer Are there other illnesses in you family such as diabetes, cholesterol, breast cancer, heart disease, prostate cancer, colon cancer, anemia, rheumatological problems, allergies, kidney disease, or anything else you feel is important? ______________________________________________________________________________________________ ______________________________________________________________________________________________ _ Who lives with you? ___________________________________________________________________________ Do you smoke? Yes No 7. If not, have you ever smoked? Yes No How much did/do you smoke each day? ___________ 9. How many years had/have you smoked? _____________ How much alcohol do you drink each day? _____ 11. Do you feel you have ever had a drinking problem? ______ Have you ever used cocaine, marijuana, heroin or other recreational drugs? Yes No Do you wear seatbelt regularly? Yes No 14. Do you exercise regularly? Yes No What exercise do you do? __________________________________ How often? ______________________ Is there anything that restricts you from doing the activities you want to do? Yes No Have you lost or gained more than 10 pounds in the last 3 months without trying or wanting to loose weight? Yes No Have you had nausea or vomiting of food or fluid for the past 5 days? Yes No Have you had any problems eating or drinking food recently (e.g. poor appetite, difficulty chewing or swallowing)? Yes No Do you experience pain part of your daily life? Yes No If yes, describe the location (s): onset; duration and characteristics of your pain (e.g. ache, burn, throb, sharp) ______________________________________________________________________________________________ ______________________________________________________________________________________________ Has anyone ever hurt or threatened to hurt you or someone else that you care about? HAVE YOU EVER BEEN IN COUNSELING BEFORE? Have you seen your doctor within the last year? Why have you seen your doctor? Are you taking any kind of medical prescription or over the counter (herbal medicines, vitamins, etc?) Do you have allergies to any medicines? Yes___ No___ How would you rate your current physical health? Please circle: Poor Unsatisfactory Satisfactory Good Very Good How many times per week do you currently exercise?________________ Type of exercise ______________________________________________ Please list any difficulties you experience with your appetite or any eating problems: ______________________________________________________________________ Do you or have you used tobacco in any form? Current___ Past___ None___ If yes, what form?__________________ Amount per day?___ Do you or have you used alcohol? Current___ Past___ None____ If current, how many drinks per day____ or week____ or month____? Have you ever been referred for treatment for alcohol use? Yes___ No___ Do you or have you used caffeine in any form (coffee, tea, cola, etc)? If so, amount per day___________________________________________________________ Do you or have you used recreational drugs? Have you ever been referred for treatment for drug use? Yes___ No___ Are you currently involved in a romantic relationship? Yes___ No___ If yes, how long?____ On a scale of 1-10, please rate your satisfaction with your relationship. ______ Please indicate any significant life changes or stressors you have recently experienced. What are your strengths? What are your weaknesses? What are your goals for treatment? Have you ever had a life threatening allergic reaction to anything? Are you pregnant or nursing (lactating)? Do you have sickle cell anemia? Do you have any history of cancer? Have you had a capsule endoscopy in the last 30 days? Have you ever sought medical attention for a piece of metal in your eye? Do you have difficulty standing without assistance? Are you claustrophobic? If YES, do you need a sedative? Is the patient physically/mentally impaired or unresponsive? Do you have uncontrollable shaking or breathing problems? Do you have trouble lying on your back for more than one hour? Do you have any of the following items inside of or on your body? |