• Heartburn New Patient Information

  • You must submit your completed packet prior to scheduling your first individual appointment.


    This form includes a personal medical history questionnaire, which must be completed in full. Please complete  prior to your first consultation.


    It is very important that you arrive on time for your scheduled office visits. If you are late, it may be necessary to reschedule.


    If you are unable to keep your appointment, please call and notify us at least 24 hours in advance. This will allow us to reschedule with another patient.


    Thank you again for choosing Bingham Healthcare Heartburn and Reflux Center.

  • PATIENT HEALTH HISTORY QUESTIONNAIRE

  • The following information is very important to your health. Please take time to fully and completely fill out this questionnaire. If there is not room for a complete history, please use additional paper.
  • DOB:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Please list any specialty physicians you have seen in the past or are currently seeing if it relates to the issue, along with their addresses and phone numbers.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • 1. Allergies

  • 1. Allergies List allergies and type of known reaction:
    Rows

  • 2. Medications

  • 2. List your current medication including vitamins. All medications must be listed here.
    Rows
  • Have you taken any weight loss medications? If so, list the name of medications and when you took it.
    Rows
  • Do you take ibuprofen/NSAIDs or other anti-inflammatory medications?

  • 3. Past Medical History

  • 3. List all operations and the year they were performed (including endoscopies):
    Rows
  • List all hospitalizations, reason, and year:
    Rows

  • Have you had the following?

  • Diabetes:*
  • Polycystic Ovarian Syndrome:*
  • Asthma, Emphysema, Tuberculosis, etc.:*
  • Eating Disorder:*
  • High Blood Pressure:*
  • Depression:*
  • Arthritis:*
  • Heart Disease:*
  • High Cholesterol:*
  • Seizures, Stroke, Paralysis:*
  • Bleeding Problems:*
  • Non Healing Wound:*
  • GERD (reflux/heart burn):*
  • Ulcers (stomach/intestinal):*
  • Cancer:*
  • Venous Stasis:*
  • Obstructive Sleep Apnea:*
  • Kidney or Bladder Disease:*
  • Infectious Diseases:*
  • COPD:*
  • Stress Incontinence:*
  • Liver Disease:*
  • Dialysis:*
  • Autoimmune Disease:*
  • Lower Extremity Edema:*

  • 4. Family History

  • Have there been any of the following diseases in your family? Please indicate if any family members died from these diseases.
  • Bleeding Disorders:*
  • Diabetes:*
  • Family History of Obesity?*
  • Stroke or Paralysis*
  • High Blood Pressure*
  • Family history of Anesthesia Complications?*
  • Cancer*
  • Lung Disease (Asthma, emphysema, TB)*

  • 5. For Female Patients only:

  • Normal:
  • Date of last breast exam:
  • Have you ever had a miscarriage:
  • Do you plan to have more children?

  • 6. Social History

  • *
  • Do you have children?*
  • Have you ever smoked?*
  • Other nicotine use?
  • Do you drink alcohol?*
  • Have you ever used recreational drugs?*

  • 7. Initial History and Review of Symptoms

  • Constitutional
  • Respiratory
  • Hematologic/Lymphatic
  • Neurological
  • Eyes
  • Cardiovascular
  • Genitourinary
  • Musculoskeletal
  • ENT, Mouth, Face
  • Gastriontestinal
  • Integument/Breast
  • Behavioral/Psych
  • Endocrine
  • Endocrine
  • Allergy/Immunologic

  • 8. CPAP Use

  • Do you use a CPAP, BiPap, or supplemental oxygen?*

  • 9. Symptom Check

  • How often do you experience heartburn (a burning sensation in your chest)?
  • Do you ever experience a sour taste in your mouth or the sensation of acid backing up in your throat?
  • Do you have difficulty swallowing food or feel like food gets stuck in your throat?**
  • Do you have a chronic cough, hoarseness, or frequent throat cleaning no related to a cold?**
  • Do your symptoms worsen after meals or when lying down?**
  • Do you wake up at night due to heartburn or regurgitation?**
  • How much are your symptoms affecting your daily life or sleep?**

  • 10. Current Management

  • Are you currently taking any over-the-counter or prescription medications for heartburn or reflux?**
  • Have you ever been diagnosed with GERD (gastroesophageal reflux disease) or any other digestive condition
  •  
  • Should be Empty: