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Digestive Health Associates & Center of Reno
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Patient Medical History Form
Patient Medical History Form
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PT Account Number
DHA MD
Date
MM slash DD slash YYYY
Time
Patient Name
Date of Birth
Sec
MALE
FEMALE
Marital Status
Occupation
Referring Physician
Reason for Appointment
Appointment:
New Patient
Follow-up
CURRENT MEDICATION(S) & DOSE
CURRENT MEDICATION(S) & DOSE
DRUG REACTIONS: ALLERGIES OR SENSITIVITIES
DRUG REACTIONS: ALLERGIES OR SENSITIVITIES
PAST HOSPITALIZATION/SURGERIES (DATE/REASON)
PAST HOSPITALIZATION/SURGERIES (DATE/REASON)
FAMILY MEDICAL HISTORY (PATERNAL/MATERNAL/SIBLING)
Bleeding Disorder
Yes
No
If Yes, Indicate Family Member
Cancer
Yes
No
If Yes, Indicate Family Member
Colon Cancer
Yes
No
If Yes, Indicate Family Member
Diabetes
Yes
No
If Yes, Indicate Family Member
Heart Disease
Yes
No
If Yes, Indicate Family Member
High Blood Pressure
Yes
No
If Yes, Indicate Family Member
Liver Disease
Yes
No
If Yes, Indicate Family Member
Stroke
Yes
No
If Yes, Indicate Family Member
Other
Yes
No
If Yes, Indicate Family Member
PERSONAL HISTORY
Smoking? History of?
Yes
No
Comments
If Yes, How Many Cigarettes Per Day?
If Yes, How Many Years?
Alcohol?
Yes
No
Comments
If Yes, How Many Drinks/Day?
History of Drug Use?
Yes
No
Comments
If Yes, How Many Years?
VITAL SIGNS (CLINICAL STAFF TO COMPLETE)
HT
WT
BP
HR
RR
PATIENT MEDICAL HISTORY
Do you have, or have you ever had in the past, any of the following?
Gastrointestinal
Disease of the esophagus
Pain or trouble swallowing
Food gets stuck
Heartburn
Hiatal hernia
Recent nausea or vomiting
Recent vomiting blood
Recent stomach pain
Ulcers
Bowel obstruction
Appendicitis or hernia
Ileitis or colitis
Recent abdominal cramps/pain
Diverticulosis
Recent loss of appetite
Recent fever, chills, sweats
Recent change in bowel habits
Recent constipation
Recent diarrhea
Recent change in size of stool
Recent blood in stool/rectal bleeding
Black, tarry stools
Hemorrhoids
Recent loss of bowel control
Gallbladder disease/stones
Liver disease
Hepatitis
Exposure to hepatitis
Blood transfusions
Jaundice
Pancreatitis
Pancreatic disease
Skin
Itching or rash
Skin diseases
HEENT
Blind spots
Double or blurred vision
Failing vision
Eye pain, glaucoma
Deafness
Ringing in the ears
Sinusitis
Nose bleeds
Hayfever
Sore throats, tonsillitis
Allergy
Seasonal allergies
Food allergies
Pulmonary
Increasing sputum production
Asthma/emphysema
Bronchitis
Pneumonia
Lung tumor
Other lung disease
Shortness of breath
Ankle swelling
Cardiovascular
Heart attack
Any heart valve disease
Enlarged heart
Chest Pain
Aneurysms
High blood pressure
Blood clots
Phlebitis
Arrhythmia
Pacemaker/AICD
Hematologic
Anemia
Bleeding Tendencies
Other blood diseases
Genitourinary
Pus in urine
Blood in urine
Loss of urine control
Kidney or bladder infections
Kidney or bladder stones
Other kidney diseases
Rheumatologic
Swollen joints
Aching muscles or joints
Gout
Lupus
Auto Immune Disease
Endocrine
Diabetes
Hyper or hypothyroidism
Adrenal disease
Neurologic
Headaches
Blackouts
Dizzy spells/lightheadedness
Weakness or paralysis
Strokes
Loss of sensation
Psychiatric
Anxiety or depressions
Suicidal or homicidal ideas
Nervous breakdown
Psychiatric problems
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