Patient Medical Questionnaire
Today's Date
*
-
Month
-
Day
Year
Date
Are you a new or existing patient?
*
New Patient
Existing Patient
Reason for filling out this form?
*
Scheduling an Office Visit
Scheduling a Procedure
Personal Information
Name
*
First Name
Last Name
Social Security Number
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Sex
*
Female
Male
Height
*
Height in inches
Weight
*
Weight in pounds
Address
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Home Phone
*
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Preferred Phone Number
Home Phone
Work Phone
Cell Phone
Best phone number to reach you during the day? M-F from 7:30am to 3:30pm
Email
*
example@example.com
How did you hear about us?
Established Patient
Physician Referral
Friend or Relative
Printed Ad
Marketing Event
Radio Ad
Internet
Newsletter
TV Media
Problem or reason for your visit?
*
Referring Physician
Primary Care Physician
*
Other Physicians
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Insurance Information
Insurance Name
*
Insurance ID#
*
Group#
Are you the primary subscriber?
*
Yes
No
Subscriber's Name
First Name
Last Name
Relationship to Subscriber
Subscriber's Date of Birth
-
Month
-
Day
Year
Date
Subscriber's Social Security Number
Do you have secondary insurance?
*
No
Yes
Secondary Insurance Information
Secondary Insurance Name
Secondary Insurance ID#
Secondary Group#
Are you the primary subscriber for the secondary insurance?
Yes
No
Secondary Insurance Subscriber's Name
First Name
Last Name
Secondary Insurance Relationship to Subscriber
Secondary Insurance Subscriber's Date of Birth
-
Month
-
Day
Year
Date
Secondary Insurance Subscriber's Social Security Number
Do you have a living will?
*
Yes
No
Do you have power of attorney for health care decisions?
*
Yes
No
Have you had an influenza immunization within the past twelve months?
*
Yes
No
When was your last influenza immunization?
-
Month
-
Day
Year
Date
Have you ever had a pneumonia vaccination?
*
Yes
No
Have you had a PPD (Purified Protein Derivative) test to determine the presence/absence of tuberculosis?
*
Yes
No
When was your last PPD (Purified Protein Derivative) test?
-
Month
-
Day
Year
Date
Have you had a screening mammogram within the last 2 years?
Yes
No
Have you had osteoporosis screening (DXA) within the last twelve months?
Yes
No
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Social History
Marital Status
*
Single
Married
Divorced
Widowed
Employment Status
*
Full Time
Part Time
Unemployed
Retired
Disabled
Occupation
Stress Issues?
*
Work Related
Recent Trauma
Illness in Family
Relationship Issues
Family Issues
Other
Tobacco
*
Current Every Day Smoker
Current Some Day Smoker
Former Smoker
Never Smoked
Cigarettes
Chew Tobacco
Cigars
Other
Preferred Language
*
English
Spanish
Vietnamese
Other
This info has been requested by the Department of Health & Human Services.
If other, please specify preferred language.
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Native Hawaiian
Other Pacific Islander
Choose not to report
This info has been requested by the Department of Health & Human Services.
Race
*
American Indian
Alaska Native
Black or African American
Native Hawaiian
Other Pacific Islander
More than one race
White
Choose not to report
This info has been requested by the Department of Health & Human Services.
Comments
Do you drink alcohol?
*
No
Yes
Alcohol
Beer
Wine
Liquor
Other
How often to you consume alcohol?
*
Daily
Occasionally
Weekly
Never
Other
Caffeine
*
Yes - One Serving Per Day
Yes - Two Serving Per Day
Yes - Three Serving Per Day
Yes - Four Serving Per Day
Yes - Five or More Serving Per Day
No
Are you on any special diets?
*
Diabetes
Cardiac
Celiac Sprue
Lactose Free
Vegan
N/A
Other
Recreational Drugs?
*
No
Yes
Recreational Drug Type
Current Recreational Drug
Previous Recreational Drug
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Medications
List all medications you presently take including aspirin, vitamins, calcium, laxatives, stool bulking agents, over-the-counter pills, eye drops, etc. Also list medications that you take occasionally.
Preferred Pharmacies
*
Do you take Aspirin?
*
No
Yes
Do you currently take any medications?
*
No
Yes
Medications
*
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Allergies
List all allergies to drugs, medicines, bee sting, etc. and give reaction.
Are you allergic to any of the following?
*
Eggs
Peanuts
Soy
Latex
Penicillin
N/A
Other
If so, what was your reaction?
Have you ever had a problem with anesthesia in the past?
*
No
Yes
If yes, what was your reaction?
Have you been advised to take antibiotics before medical or dental procedures?
No
Yes
If yes, please provide the reason.
Do you have any drug allergies?
*
No
Yes
Drug Allergies
*
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Previous GI Evaluations
Give the year, location (hospital or x-ray office) if not ordered or performed by our practice.
Have you ever had any previous GI evaluations?
*
No
Yes
Colonoscopy
Upper Endoscopy (EGD)
Abdominal CAT (CT) Scan
Abdominal Sonogram (Ultrasound)
Barium Enema
Upper GI Series
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Operations
List ALL surgical operations.
Have you ever had any operations?
*
No
Yes
Operation
*
Artificial joints, implants, metal or mesh in your body?
*
No
Yes
If yes, please explain by describing it and the location on your body.
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Gastrointestinal History
Upper GI Issues
Frequent Mouth Ulcers
Stomach Ulcers
Heart Burn
Nausea
Difficulty Swallowing or Food Sticking
Painful Swallowing
Excessive Belching
Weight Gain
Weight Loss
Black Stool
Other
Lower GI Issues
Bloating
Excessive Rectal Gas/Flatus
Painful Bowel Movements
Constipation
Rectal Bleeding
Diarrhea
Lower Abdominal Pain
Colon Cancer
Loss of Stool/Fecal Accidents
Other
Have you experienced unexplained weight loss?
If so, describe how much in pounds.
Do you have a family history of colon cancer or colon polyps?
*
If so, please explain.
Issues with Digestive Organs
Liver
Yellow Eyes (Jaundice)
Liver Transplant
History of Blood Transfusions
Cirrhosis
Elevated Liver Blood Test
Fatty Liver Disease
Hepatitis
Hepatitis A
Hepatitis B Vaccination
Hepatitis B
Hepatitis C
Other
Gallbladder
Gallstones
Gallbladder Surgery
Other
Pancreas
Pancreatitis
Other
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Family History
Please provide the following information on your parents, siblings and children.
Father
*
Father's Gastrointestinal History
Colon Cancer
Colon Polyps
Ulcerative Colitis
Crohn's
Irritable Bowel Syndrome
Liver Disease
Other
Mother
*
Mother's Gastrointestinal History
Colon Cancer
Colon Polyps
Ulcerative Colitis
Crohn's
Irritable Bowel Syndrome
Liver Disease
Other
Do you have siblings?
*
No
Yes
Sibling(s)
Sibling's Gastrointestinal History
Colon Cancer
Colon Polyps
Ulcerative Colitis
Crohn's
Irritable Bowel Syndrome
Liver Disease
Other
Do you have children?
*
No
Yes
Children
Children's Gastrointestinal History
Colon Cancer
Colon Polyps
Ulcerative Colitis
Crohn's
Irritable Bowel Syndrome
Liver Disease
Other
Paternal Grandfather Gastrointestinal History
Colon Cancer
Colon Polyps
Ulcerative Colitis
Crohn's
Irritable Bowel Syndrome
Liver Disease
Other
Paternal Grandmother Gastrointestinal History
Colon Cancer
Colon Polyps
Ulcerative Colitis
Crohn's
Irritable Bowel Syndrome
Liver Disease
Other
Maternal Grandfather Gastrointestinal History
Colon Cancer
Colon Polyps
Ulcerative Colitis
Crohn's
Irritable Bowel Syndrome
Liver Disease
Other
Maternal Grandmother Gastrointestinal History
Colon Cancer
Colon Polyps
Ulcerative Colitis
Crohn's
Irritable Bowel Syndrome
Liver Disease
Other
Please add any other important family health information.
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Your Medical History
Do yo have history of any of the following?
Heart
Murmur
High Cholesterol
Pacemaker
History of Heart Attack
Palpitations
Angina
Previously Underwent a Cardiac Catherization
Congestive Heart Failure
Heart Transplant
High Blood Pressure
Heart Valve Replacement
Mitral Valve Prolapse
Cardiac Stents
Irregular Heartbeat
Open Heart Surgery
History of Blood Clots
Bleeding Disorder
Other
Lung
Asthma
Emphysema
Difficulty Breathing With Walking
Lung Cancer
Difficulty Breathing Lying Down
Chronic Cough
Lung Transplant
Chronic Obstructive Pulmonary Disease (COPD)
Oxygen Use
Sleep Apnea
Other
Urinary
Kidney Stones
Kidney Transplant
Cancer of the Kidney
Kidney Disease
Hemodialysis
Peritoneal Dialysis
Other
Endocrine
Thyroid Problem
Goiter
Diabetes
Insulin Dependent
Other
Infectious Diseases
TB
Herpes
HIV
C-Diff
MRSA
VRE
Shingles
Other
Reproductive (Female)
Are You Pregnant or Planning a Pregnancy
Menstrual Irregularity
Post-menopausal
Sexually Transmitted Disease
Uterine Cancer
Breast Cancer
Endometrial Cancer
Other
How many deliveries have you had (female)?
Reproductive (Male)
Enlarged Prostate
Sexually Transmitted Disease
Erectile Dysfunction
Prostate Cancer
Other
If you have had or have prostate cancer, please specify the type(s) of treatment.
Do you or have you had any type of cancer?
*
No
Yes
If yes, please explain in detail.
What type of cancer did/do you have?
Explain what type of cancer treatment(s) you've had.
Nervous System
Fainting
Migraine Headaches
Epilepsy
Restless Leg Syndrome
History of Stroke or TIA
Chronic Headaches (Not Migraine)
Insomnia
Other
Skin Conditions
Psoriasis
Skin Cancer
Eczema
Melanoma
Acne
Other
Other Conditions
ADD/ADHD
Anxiety
Bipolar Disorder
Depression
OCD
Schizophrenia
Other
Eyes
Cataracts
Glaucoma
Blindness
Other
Ears
Difficulty Hearing
Hearing Aids
Other
Muscular/Skeletal
Arthritis
Leg Cramps at Night
Chronic Fatigue
Degenerative Joint Disease
Back Problems
Fibromyalgia
Gout
Osteopenia
Osteoporosis
Other
Please list any health problems not mentioned above.
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