California Advanced Gastroenterology

"Our bowels are at their best when they function silently and with only intermittent recognition.” 
Sherwood Gorbach, 1974

 

  Medical History
 

  Date
                (mm/dd/yy)

  Name   
                (first mi last)                                                       

  Age 

  Primary or Referring Physician

  Reason for Consultation  
                                               

  Additional Medical Problems (check those which apply)

         

High Blood Pressure 

            Diabetes Mellitus          
  Asthma, Emphysema   High Cholesterol           
  Stroke or TIA Thyroid Problems          
Arthritis                          Seizures                   
Anxiety Depression

Heart Attack

Congestive Heart Failure
Heart Murmur Arrhythmia
Bleeding Disorder Headaches
Cancer If so, what type and when?
Other conditions or illnesses not mentioned above

  Prior Surgery (type of surgery and approximate year—most recent first if possible)

    1.

    2.

    3.

    4.

    5.

    6.                            

  Current Medications (names only, doses not necessary)

    1.        5.

    2.        6.

    3.        7.

    4.        8.

 

  Social History  
 
     Do you smoke?  yes    no      
               If so, how much per day?

    Do you drink alcohol, including wine or beer?  yes  no
                If so, how much do you drink per week? 

    Occupation:

    Marital status:   S    M   D   W   Other

 

  Family History: (immediate family members only)

     Of colon cancer or polyps?   yes  no   
               If yes, please specify

     Of liver disease?   yes  no  
               If yes, please specify

     Of stomach, esophageal or pancreatic cancer?  yes  no 
               If yes, please specify

 

  Just a few last questions:

    1. Do you take aspirin, anti-inflammatory pain relievers, or arthritis medications, other than Tylenol?  yes   no  
               If so, which ones and  approximately how often?        

    2. Have you had any recent tests (blood, scans, or x-rays) that you believe would help us in your care?  yes no.
              If so, please ask your doctor to fax them to us (863-1234) and inform our office staff.

    3. Have you seen another gastroenterologist before?  yes   no .
              If so, please note the doctor's name and when you last saw him or her