Patient History Questionairre

Patient History Questionairre

Ganesh Deshmukh MD & Adeyemo Adewunmi MD & Vishnu Pemmaraju MD
Today's Date

MonthDayYear
Date
Name

First NameMiddle NameLast Name
Date Of Birth

MonthDayYear
Date
Email
example@example.com
Reason For Visit

How long have you had this problem?

Rows	days	weeks	months	years
enter number

How severe is the problem?
Allergies
Please list your medications*
none
Do you take blood thinners?*

EliquisPlavixCoumadinOther, please list abovenone
Anorectal Problems:*

Blood in StoolBurning after BMPain after BMContinuous Anorectal PainProtrusionItchingLeakage of Mucous or StoolNo Anorectal Problems
Abdominal symptoms:*

NauseaVomitingBloatingAbdominal PainDiarrheaConstipationHeartburnDifficulty SwallowingNo Abdominal Symptoms

Abdominal Pain:

Abdominal Pain Location:

Cardiovascular Problems*

chest painshortness of breatharrythmiasnone
Respiratory Problems*

coughblood in sputumasthma attacksnone
Neurological Problems

dizzinessweakness in arms or legsseizure disorderloss of sensation in any part of bodynone
Urinary symptoms

cloudy urineblood in urinepassing air when urinatingnone
Liver disease*

jaundicegeneralized itchingbiliary colicbleeding disordernone
Musculoskeletal problems

joint painslumps over arms or legsdifficulty walkingnone
Medical History*

Bleeding DisordersHypertensionChronic lung diseaseStrokecolitisGERDChronic kidney diseaseOrgan transplantCoronary artery diseaseCrohn's diseaseDiabetesPast cancersOther illnesses, please enter in box belowNone
Other illnesses
Do you have a pacemaker or Defibrillator*
Date of last colonoscopy, leave blank if no previous colonoscopy

MonthDayYear
Date
Findings on last colonoscopy, enter N/A if no previous colonoscopy
Other findings on colonoscopy
Previous surgical history*

colectomyabdominal hernia repairhysterectomycholecystectomybladder or prostate surgeryColonoscopyUpper gastrointestinal endoscopyOther, please specify in next boxNone
Other surgery
none

Family History of Cancers*

Social History*

current smokerformer smokerrecreational drugssocial alcohol consumptionDaily alcohol consumptionnone of the above
Activity*

sedentarymoderately activevary active lifestyle
Sexual Preferences*

not sexually activeOpposite sexSame sexOther
Signature
Please verify that you are human*
Should be Empty: