Health History Form
Samuel Marcus MD, PhD
Date
*
/
Month
/
Day
Year
Date
Name
*
First Name
Last Name
Age
*
Weight
*
Height
*
Please state the reason(s) you have an appointment with our office.
*
1. Have you had pain in your upper abdomen? (above the navel)
Yes
No
2. Do you have pain in the upper abdomen that you can locate with one finger?
Yes
No
3. Does your pain spread throughout your upper abdomen?
Yes
No
4. Do you have difficulting swallowing food or liquids?
Yes
No
5. Do you have heartburn? (burning in your chest or throat)
Yes
No
6. Do you have chest pressure or tightness?
Yes
No
7. Do you notice any of the following tastes in your mouth?
Metallic
Bitter
Acid
Sour
None
8. Do you often have a hoarse voice?
Yes
No
9. Do you often have to clear your throat of mucus?
Yes
No
10. Do you often cough?
Yes
No
11. Do you have difficulting swallowing...
Liquids
Solid foods
Tablets
None
12. Does it hurt when you swallow?
Yes
No
13. Do you feel bloated after a meal?
Yes
No
14. Do you feel bloated in your upper abdomen?
Yes
No
15. Do you have difficulting completing your meals?
Yes
No
16. Do you feel as if you might vomit after a meal?
Yes
No
17. Do you combit after a meal?
Yes
No
18. Have you vomited blood?
Yes
No
19. Do you feel sick at other times of the day?
Yes
No
20. Do you get pain in your upper abdomen after eating fatty or greasy foods?
Yes
No
21. Do you belch more than normal?
Yes
No
22. Does abdominal pain wake you up at night?
Yes
No
23. Is the pain in your abdomen relieved by eating?
Yes
No
24. Is the pain relieved by taking over-the-counter antacids?
Yes
No
25. Do you have pain in your lower abdomen?
Yes
No
26. Is this pain relieved by bowel movements or passing gas?
Yes
No
27. Have you had a change in the frequent, shape, or consistency of your bowel movements?
Yes
No
28. Have you had a recurrent diarrhea, or do you have continuous diarrhea?
Yes
No
29. Have you had problems with an episode of constipation, or do you have frequent or chronic constipation?
Yes
No
30. Have you had an urgent need to have a bowel movement that makes you rush to the toilet?
Yes
No
31. Do you sometimes not make it to the toilet in time?
Yes
No
32. Do you have to strain while having a bowel movement?
Yes
No
33. Do you have rectal pain in association with a bowel movement, or at any other time such as in the middle of the night?
Yes
No
34. Have you felt unable to complete your bowel movement?
Yes
No
35. Do you see blood?
On the toilet paper
On the surface of the stool
Mixed in with the stool
In the water of the toilet bowl
No
36. Do you have black tarry stools?
Yes
No
37. Do you see mucus in your stool?
Yes
No
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Gastrointestinal History
Check if you currently have OR have had any of the following:
Ulcerative colitis
Crohn's colitis
Crohn's enteritis (small entestine)
Crohn's Ileocolitis (small intestinal and colon)
Gallstones
Gallbladder Disease
Fatty liver disease
hepatitis
Cirrhosis of the liver
Liver cysts or tumor
Pancreatic problems
Colon polyps
H. pylori stomach infection
Esophageal problems
Peptic ulcer
Acid reflux
Gastrointestinal bleeding
Anemia
Blood Transfusion
If answered 'yes' to Blood transfusion - When?
Cancer
Colon
Rectal
Liver
Pancreas
Stomach
Esophageal
Anal
Other
Alcohol-related illness
Anorexia nervosa
Bilimia
Lactose intolorance
Celiac disease
Irritable bowel syndrome
Hemochromatosis
Hemorrhoids
Anal fissure/fistula
Enema use
Diverticulosis
Divertculitis
Chronic Constipation
Chronic diarrhea
Colon polyps
NONE
Check if you have undergone
Colonoscopy
Sigmoidoscopy
Upper Endoscopy
None
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General Medical Conditions
Check if you currently have OR have had any of the following:
General Medical Condition
AIDS
Anxiety disorders
Arthritis
Asthma
Atrial fibrations or other arrhythmias
Bleeding disorders
Blood clotting disorders
Chicken pox
Chronic bronchitis
Congestive heart failure
COPD
Dementia
Depression
Diabetes (non-insulin-dependent)
Diabetes (insulin-dependent)
Drug abuse
Electrolyte imbalance
Emphysema
General Medical Condition Part 2
Epilepsy
Goiter
Gout
Heart attack
Heart disease
Heart murmur
Herpes
High cholesterol
HIV positive
Hypertension
Kidney disease
Kidney stones
Migraine headaches
Multiple sclerosis
Osteoporosis
Pacemaker
Pneumonia
Prostate problems
General Medical Conditions part 3
Psychiatric care
Rheumatic fever
Sleep apnea
Seizure disorders
Stroke
Thyroid problems
Tuberculosis
Positive PPD TB test
Problems with anesthesia
Valvular heart disease
Multiple drug allergies
Severe allergic reactions
Cancer
Breast
Thyroid
Prostate
Skin
Other
Check any surgeries you have had and state the approximate year
Appendix
Yes
Approximate Date
Breast
Yes
Approximate Date
CABG
Yes
Approximate Date
Cataract
Yes
Approximate Date
Cesarean delivery
Yes
Approximate Date
Colon/Bowel
Yes
Approximate Date
D&C
Yes
Approximate Date
Esophagus
Yes
Approximate Date
Gallbladder
Yes
Approximate Date
Hemorrhoids
Yes
Approximate Date
Hernia
Yes
Approximate Date
Hysterectomy
Yes
Approximate Date
Ortheopedic
Yes
Approximate Date
Ovarian
Yes
Approximate Date
Pancreas
Yes
Approximate Date
Prostate
Yes
Approximate Date
Stent Placement
Yes
Approximate Date
Stomach
Yes
Approximate Date
Tonsils
Yes
Approximate Date
Tubal Ligation
Yes
Approximate Date
Tubal Ligation
Yes
Approximate Date
Other
Other
Approximate Date
List any other hospitalizations, illnesses, or possible conditions:
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Medication List
Select if you are NOT taking ANY medication.
None
Have you taken any antibiotics in the past 30 days?
Yes
No
If yes, which drug?
Do you take blood thinners?
Yes
No
Do you take Aspirin?
Yes
No
Do you take Fish Oil?
Yes
No
Do you take Vitamins?
Yes
No
Do you take Herbals?
Yes
No
If you take medicine, list the name of the medicine, the dose, and how often you take a dose.
Do you routinely take over-the-counter medication?
Yes
No
Medication Allergies
List if you are allergic to:
Are you allergic to Penicillins?
Yes
No
Are you allergic to Sulfa drugs?
Yes
No
Are you allergic to other medications?
Yes
No
If yes to other medication, please list which ones:
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Personal Habits
Have you ever smoked cigarettes regularly?
Yes
No
If yes, what age did you start?
What age did you stop?
Number of cigarettes per day?
Number of years you smoked.
Do you drink every day?
Yes
No
How many drinks per week?
Have you ever felt badly about something that happened because of your drinking?
Yes
No
Do you use or have used recreational drugs?
Yes
No
If yes, which ones?
Do you have any dietary restrictions?
Yes
No
If yes, please check all that are appropriate:
Vegetarian
Vegan
Lactose Intolerance
Diet free of red meat
Gluten
Other
Sexual History - Relations
Do you prefer:
Men
Women
Both
Abstinent
Have you had relations with someone who is sexually promiscuous or who has HIV/AIDS?
Yes
No
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Social History
Where were you born?
Relationship Status
Do you have children?
Please list your current or past professions:
Family History
Where was your mother born?
Age if living
Age of death
Where was your father born?
Age if living
Age of death
Please indicate who in your family may have had the following
M= Mother F = Father S = Sibling GP = Grandparent C = Child
Celiac Disease
Colitis
Crohn's Disease
Colon Polyps
Liver Disease
Hepatitis B or C
Peptic Ulcer Disease
Breast Cancer
Esophageal
Stomach
Pancreas
Liver
Colon
Other
Hypertension
Stroke
Heart Disease
Diabetes
Arthritis
Osteoporosis
Anemia
Alcoholism
Drug Addiction
Have any of your blood relative had colon or rectal cancer?
Yes
No
If yes, who?
Age the cancer was diagnosed
Have any of your blood relatives had colon polyps?
Yes
No
If yes, who?
Have any of your blood relatives had gastric or esophageal cancer?
Yes
No
If yes, who?
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Review of Symptoms
Please select problem areas
General
Loss of appetite
Recent weight loss or gain
Fever
Weakness
Other
Skin
Itching
Rash
Other
Ears & Eyes
Ears - Infections
Ears - Loss of hearing
Eyes - Redness
Eyes - Cataracts
Other
Nose
Nosebleeds
Chronic postnassal
Hay fever
Other
Mouth & Throat
Bleeding gums
Sore throat
Hoarseness
Mouth sores
Chest
Coughing
Sputum
Breathlessness
Coughing blood
Wheezing
Heart
Chest Pain
Palpitations
Shortness of breath
Breathlessness when lying down
Waking up breathless from sleep
Ankle swelling
Other
Urinary
Increased frequency
Blood in urine
Pain with urination
Urinating more than 2 times a night
Other
Musculoskeletal
Joint pain
Joint swelling
Muscle weakness or pain
Other
Endocrine
Excess thirst
Heat or cold intolerance
Other
Neurologic
Headaches
loss of consciousness
Seizures
Persistence tingling
Numbness
Paralysis
Other
Hematologic
Easy bruising
Excessive bleeding if cut or after dental extractions
Female
dates
Last normal menstrual period
Last mammogram
Last Pap smear
Last DEXA bone scan
None
None
Submit
Should be Empty: