CDHN Health History Form

Name* This field is required.

First Name

Last Name

Suffix

Patient's Date of Birth* This field is required.

Date of birth

Reason for your visit and/or primary concerns?* This field is required.

Who is your Primary Care Physician?* This field is required.

Best phone number to contact you?

Area Code

Phone Number

What is your pharmacy and location?* This field is required.Please include if you have more than one pharmacy and/or a mail order pharmacy. List in order of preference

Appointment Date & Time

Date

Hour

Minutes

Type of Appointment

MEDICATIONS* This field is required.**SEPARATE EACH MEDICATION WITH A COMMA, if none write NONE.

List all medications, dosages and frequency of medications - INCLUDE VITAMINS AND SUPPLEMENTS

Allergies* This field is required.*SEPARATE EACH ENTRY WITH A COMMA

Separate each entry with a comma

Do you have an allergy to Latex, Egg, Soy, or Iodine/Contrast Dye?* This field is required.If yes, please indicate which one/s. If no, write NO

ex: yes to latex and contrast dye only

ALLERGY TO EGGYES OR NO

ALLERGY TO SOYYES OR NO

ALLERGY TO IODINE/CONTRAST DYEYES OR NO

Marital Status* This field is required.

single

divorced

married

widowed

Race* This field is required.

Caucasian

African American

Hispanic

American Indian

other

Asian

More than one race

Ethnicity* This field is required.

Hispanic or Latino

Not Hispanic or Latino

unreported

Undefined

Language* This field is required.

English

Spanish

American Sign Language

Other

Has a family member of yours had anesthesia problems post-surgery?* This field is required.

yes

Have you personally had any problems with anesthesia post-surgery?* This field is required.

yes

If yes, did you have any of these symptoms?

nausea

vomiting

difficult intubation

Other

General* This field is required.Mark all symptoms or diagnoses you CURRENTLY have

tiredness

fever

night sweats

lack of appetite

unintentional weight loss (over 10 Ibs.)

NONE

Head, Ears, Eyes, Nose & Throat* This field is required.Mark all symptoms or diagnoses you CURRENTLY have

wears glasses

hoarseness

wears contacts

headache

glaucoma

decreased hearing

NONE

Cardiovascular* This field is required.Mark all symptoms or diagnoses you CURRENTLY have

elevated blood pressure

chest pain

fainting / blacking out

heart stent

defibrillator

swelling of hands or feet

heart valve replacement

NONE

pacemaker

Genitourinary* This field is required.Mark all symptoms or diagnoses you CURRENTLY have

painful urination

change in urinary stream

frequent urination

blood in urine

pelvic pain

kidney disease

NONE

Neurological* This field is required.Mark all symptoms or diagnoses you CURRENTLY have

difficult speech

dizziness

stroke

loss of consciousness

fainting

weakness in extremities

seizure

NONE

Endocrine* This field is required.Mark all symptoms or diagnoses you CURRENTLY have

cold intolerance

excessive thirst

thyroid problem

heat intolerance

excessive urination

NONE

Musculoskeletal* This field is required.Mark all symptoms or diagnoses you CURRENTLY have

physical disability

arthritis

joint stiffness

backache

NONE

Skin* This field is required.Mark all symptoms you CURRENTLY have

rash

itching

NONE

Respiratory* This field is required.Mark all symptoms or diagnoses you CURRENTLY have

chronic cough

documented sleep apnea

wheezing

difficulty breathing

use of CPAP/BIPAP

NONE

Psychiatric* This field is required.Mark all symptoms or diagnoses you CURRENTLY have

suicidal thoughts

anxiety

depression

NONE

Blood* This field is required.Mark all symptoms or diagnoses you CURRENTLY have

easy bruising

anemia

blood thinner

blood clots

NONE

Breast* This field is required.Mark all symptoms or diagnoses you CURRENTLY have

breast pain

breast mass

NONE

Gastrointestinal* This field is required.Mark all symptoms or diagnoses you CURRENTLY have

nausea

change in bowel habits

vomiting

diarrhea

indigestion/ reflux/ heartburn

abdominal pain

gas/ flatulence

difficult/ painful swallowing

constipation

jaundice (yellow skin)

pain with bowel movement

blood in stool

NONE

Have you ever had a colonoscopy* This field is required.

yes

Have you ever had an upper endoscopy?* This field is required.

yes

Immunizations* This field is required.Please indicate if you have been immunized against the following. Mark all that apply. If none, mark “NONE.

hepatitis A

hepatitis B

flu

pneumonia

NONE

Who do you live with?* This field is required.Mark all that apply

alone

parents

spouse/ partner

other

Do you consume alcohol?* This field is required.

yes

never

in the past

How often do you consume alcohol?* This field is required.

What is your smoking status?* This field is required.

currently (every day)

currently (some days)

never

YOUR MEDICAL HISTORY* This field is required.Please indicate if YOU have had any of the following. Mark all that apply.

abnormal heartbeat / palpitations

diverticulosis

migraines

acid reflux / GERD

emphysema or COPD

osteoporosis

alcohol abuse

esophageal stricture or narrowing

ovarian cancer

anemia

esophageal cancer

pancreatitis

anxiety

fibromyalgia

prostate cancer

arthritis

gallstones

seizure disorder

asthma

glaucoma

skin cancer

barrett's esophagus

gout

staph/ MRSA infection

hearing impairment

sleep apnea

heart disease

stomach ulcer or duodenal ulcer

heart attack

stroke

hemorrhoids

thyroid disease

hepatitis C

treatment with blood thinner

high blood pressure

ulcerative colitis

bleeding disorder

blood clots

breast cancer

celiac disease

chronic constipation

bowel obstruction

none

YOUR MEDICAL HISTORY CONTINUED..* This field is required.Please indicate if YOU have had any of the following. Mark all that apply. If none, mark NONE

colon or rectal cancer

HIV positive

uterine cancer

colon polyps

Crohn's disease

jaundice/ yellow skin as an adult

dementia

kidney problems

depression

liver failure/ cirrhosis

diabetes

lupus

irritable bowel syndrome

other

NONE

SURGERY* This field is required.Please indicate if YOU have had any of the following. Mark all that apply. If none, mark "I HAVE HAD NO SURGERIES"

aortic aneurysm repair

heart valve replacement

stomach ulcer

appendectomy

hiatal hernia surgery

tubal ligation

automatic cardiac defibrillator

hip replacement

TURP

back surgery

hysterectomy (partial)

weight loss surgery

brain surgery

hysterectomy (total)

vasectomy

colon surgery

knee surgery

defibrillator

coronary artery bypass graft

pacemaker placement

gallbladder removal

prostate surgery

gastric resection

shoulder surgery

other

I HAVE HAD NO SURGERIES

If you selected other surgery please list here:

Please list any additional conditions, diseases OR diagnoses if not previously listed.

Have any of your first degree relatives had Colon Cancer?* This field is required.

yes

Have any of your first degree relatives had Colon Cancer? If “yes”, who* This field is required.

mother

father

brother

sister

other

Have any of your first degree relatives had Colon polyps?* This field is required.

yes

Have any of your first degree relatives had Colon polyps? If “yes”, who?* This field is required.

mother

father

brother

sister

other

Please indicate if YOUR FAMILY has a history of the following* This field is required.If Family history unknown, mark UNKNOWN

autoimmune hepatitis

bleeding disorder

blood clots

breast cancer

cancer, other

alcohol abuse

celiac disease

hypertension

stomach cancer

cirrhosis

irritable bowel syndrome

Crohn's disease

diabetes

heart attack

hemachromatosis

hepatitis B

hepatitis C

liver cancer

mental illness

ovarian cancer

pancreatitis

prostate cancer

sickle cell

stroke

tuberculosis (TB)

ulcerative colitis

ulcer disease

uterine cancer

other

NONE

FAMILY HISTORY UNKNOWN

Have you had bloodwork, testing or hospital visit in the last 6-8 months?* This field is required.

YESNO

If yes, where and/or who ordered the testing?

Email* This field is required.

example@example.com