Step 1 of 3 33% Name* Email Address* DATE OF BIRTH* Month Day Year AGE TODAY’S DATE Month Day Year REFERRED BY PRIMARY DOCTOR REASON FOR TODAY’S VISIT Medication (PRESCRIPTION AND OVER-THE-COUNTER) (PRESCRIPTION AND OVER-THE-COUNTER) Medication Dosage Frequency @nbsp; NON-STEROIDAL DRUG USE? (Ex: Aleve, Ibuprofen, Motrin, etc.) Yes No DO YOU TAKE ASPIRIN? Yes No DO YOU USE HERBAL PRODUCTS? Yes No DO YOU TAKE MULTIVITAMINS? Yes No DO YOU TAKE BLOOD THINNERS? Yes No Allergies ALLERGIES (CHECK ALL THAT APPLY) NONE DEMEROL LATEX VERSED PENICILLIN CODEINE SULFA IVP DYE ENVIRONMENTAL (e.g., dust, mold, pollen) Other Other Allergies Have you ever had an unusual reaction to a general or local anesthetic? Yes No Explain Have you ever received a blood or a blood-product transfusion? Yes No Year PAST MEDICAL HISTORY PAST MEDICAL HISTORY (CHECK ALL THAT APPLY) HEART DISEASE ASTHMA ARTHRITIS LUNG DISEASE/COPD COLON POLYPS HIGH BLOOD PRESSURE COLON CANCER KIDNEY DISEASE SEIZURES/EPILEPSY CELIAC DISEASE GLAUCOMA COLITIS/CROHN’S DISEASE CONGESTIVE HEART FAILURE STROKE THYROID DISEASE HEPATITIS/LIVER DISEASE DIABETES: CANCER – TYPE: OTHER: FEMALES – IS THERE ANY CHANCE THAT YOU ARE PREGNANT? Yes No PREVIOUS SURGERIES/PROCEDURES PREVIOUS SURGERIES/PROCEDURES (CHECK ALL THAT APPLY) HERNIA BACK APPENDIX TONSILS GALLBLADDER BREAST HYSTERECTOMY PACEMAKER IMPLANTED TUBAL LIGATION DEFIBRILLATOR IMPLANTED HIP REPLACEMENT KNEE REPLACEMENT HEART BYPASS SURGERY HEART VALVE REPLACED EGD – DATE: COLONOSCOPY – DATE: COLON, INTESTINAL, STOMACH SURGERY — DATE: OTHER: FAMILY HISTORY (PROVIDE RELATIONSHIP FOR ALL THAT APPLY) CELIAC DISEASE COLITIS/CROHN’S DISEASE COLON POLYPS COLON CANCER LIVER DISEASE/PROBLEMS CANCER | WHO @amp;amp; TYPE HIGH BLOOD PRESSURE KIDNEY DISEASE HEART DISEASE LUNG DISEASE DIABETES STROKE SOCIAL HISTORY (PROVIDE RELATIONSHIP FOR ALL THAT APPLY) MARITAL STATUS M S D W CAFFEINE Yes No QTY SMOKE Yes No QTY TATTOOS Yes No YEAR ALCOHOL Yes No QTY IV DRUG USE Yes No YEAR OCCUPATION Do you feel threatened, abused, neglected or exploited in your home? Yes No (If Yes, refer to EPIC Charting) REVIEW OF SYMPTOMS PLEASE CHECK YES OR NO TO ALL QUESTIONS CONSTITUTIONAL: WEIGHT LOSS Yes No WEIGHT GAIN Yes No FEVER Yes No CHILLS Yes No EYES: REDNESS Yes No DOUBLE OR BLURRED VISION Yes No ENT: HOARSENESS Yes No TROUBLE SWALLOWING Yes No HEMATOLOGIC/LYMPHATIC: BRUISING Yes No BLOOD CLOTS Yes No ANEMIA Yes No RESPIRATORY/CARDIOVASCULAR: EDEMA Yes No SHORTNESS OF BREATH Yes No CHEST PAIN Yes No NEUROLOGICAL: HEADACHES Yes No DIZZINESS Yes No HISTORY OF FALLS Yes No OTHER GASTROINTESTINAL NAUSEA Yes No VOMITING Yes No ACID REFLUX Yes No HEARTBURN Yes No DIARRHEA Yes No CONSTIPATION Yes No BLOOD IN STOOL Yes No ABDOMINAL PAIN Yes No ABDOMINAL BLOATING Yes No MUSCULOSKELETAL: BACK PAIN Yes No CHEST PAIN Yes No WEAKNESS Yes No JOINT PAIN/SWELLING Yes No UROLOGY: BLADDER PROBLEMS Yes No KIDNEY DISEASE Yes No INTEGUMENTARY: SKIN RASH Yes No PSYCHOLOGICAL ANXIETY Yes No DEPRESSION Yes No MEMORY LOSS Yes No Patient Follow-Up Call Information We need to know the best way to reach you with any test results. (For example: any biopsy results after a procedure or lab or radiology results). Phone* The best phone number to contact me by: Please indicate one of the following:* It is okay to leave a message Please DO NOT leave a message I will review my lab and/or radiology results on the patient health portal. I know I will not be called with normal results. Notice We will not disclose any health information with anyone not authorized by the Patient. It is okay to leave information or leave a message with: It is okay to text appointment reminders and forms to my cell phone: Yes No Cell Phone Number: Send my notes to the following Provider: Pharmacy: