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1
Name
*
This field is required.
First Name
Last Name
Suffix
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2
Patient's Date of Birth
*
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/
Date of birth
Month
Day
Year
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3
Reason for your visit and/or primary concerns?
*
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4
Who is your Primary Care Physician?
*
This field is required.
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5
Who referred you?
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6
Best phone number to contact you?
Area Code
Phone Number
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7
What is your pharmacy and location?
*
This field is required.
Please include if you have more than one pharmacy and/or a mail order pharmacy. List in order of preference
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8
Appointment Date & Time
-
Date
Month
Day
Year
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Minutes
AM
PM
PM
AM
PM
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9
Type of Appointment
Office Appointment
Procedure (endoscopy/colonoscopy)
Virtual
Infusion
Teaching
Office Appointment
Procedure (endoscopy/colonoscopy)
Virtual
Infusion
Teaching
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10
MEDICATIONS
*
This field is required.
**SEPARATE EACH MEDICATION WITH A COMMA, if none write NONE.
List all medications, dosages and frequency of medications - INCLUDE VITAMINS AND SUPPLEMENTS
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11
Allergies
*
This field is required.
*SEPARATE EACH ENTRY WITH A COMMA
Separate each entry with a comma
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12
Do you have an allergy to
Latex
,
Egg
,
Soy
, or
Iodine
/
Contrast Dye
?
*
This field is required.
If
yes
, please indicate which one/s. If
no
, write
NO
ex: yes to latex and contrast dye only
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13
ALLERGY TO EGG
YES OR NO
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14
ALLERGY TO SOY
YES OR NO
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15
ALLERGY TO IODINE/CONTRAST DYE
YES OR NO
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16
Marital Status
*
This field is required.
single
divorced
married
widowed
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17
Race
*
This field is required.
Caucasian
African American
Hispanic
American Indian
other
Asian
More than one race
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18
Ethnicity
*
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Hispanic or Latino
Not Hispanic or Latino
unreported
Undefined
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19
Language
*
This field is required.
English
Spanish
American Sign Language
Other
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20
Has a family member of yours had anesthesia problems post-surgery?
*
This field is required.
yes
no
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21
Have you personally had any problems with anesthesia post-surgery?
*
This field is required.
yes
no
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22
If yes, did you have any of these symptoms?
nausea
vomiting
difficult intubation
Other
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23
General
*
This field is required.
Mark all symptoms or diagnoses you CURRENTLY have
tiredness
fever
night sweats
lack of appetite
unintentional weight loss (over 10 Ibs.)
NONE
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24
Head, Ears, Eyes, Nose & Throat
*
This field is required.
Mark all symptoms or diagnoses you CURRENTLY have
wears glasses
hoarseness
wears contacts
headache
glaucoma
decreased hearing
NONE
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25
Cardiovascular
*
This field is required.
Mark all symptoms or diagnoses you CURRENTLY have
elevated blood pressure
chest pain
fainting / blacking out
heart stent
defibrillator
swelling of hands or feet
heart valve replacement
NONE
pacemaker
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26
Genitourinary
*
This field is required.
Mark all symptoms or diagnoses you CURRENTLY have
painful urination
change in urinary stream
frequent urination
blood in urine
pelvic pain
kidney disease
NONE
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27
Neurological
*
This field is required.
Mark all symptoms or diagnoses you CURRENTLY have
difficult speech
dizziness
stroke
loss of consciousness
fainting
weakness in extremities
seizure
NONE
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28
Endocrine
*
This field is required.
Mark all symptoms or diagnoses you CURRENTLY have
cold intolerance
excessive thirst
thyroid problem
heat intolerance
excessive urination
NONE
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29
Musculoskeletal
*
This field is required.
Mark all symptoms or diagnoses you CURRENTLY have
physical disability
arthritis
joint stiffness
backache
NONE
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30
Skin
*
This field is required.
Mark all symptoms you CURRENTLY have
rash
itching
NONE
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31
Respiratory
*
This field is required.
Mark all symptoms or diagnoses you CURRENTLY have
chronic cough
documented sleep apnea
wheezing
difficulty breathing
use of CPAP/BIPAP
NONE
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32
Psychiatric
*
This field is required.
Mark all symptoms or diagnoses you CURRENTLY have
suicidal thoughts
anxiety
depression
NONE
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33
Blood
*
This field is required.
Mark all symptoms or diagnoses you CURRENTLY have
easy bruising
anemia
blood thinner
blood clots
NONE
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34
Breast
*
This field is required.
Mark all symptoms or diagnoses you CURRENTLY have
breast pain
breast mass
NONE
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35
Gastrointestinal
*
This field is required.
Mark all symptoms or diagnoses you CURRENTLY have
nausea
change in bowel habits
vomiting
diarrhea
indigestion/ reflux/ heartburn
abdominal pain
gas/ flatulence
difficult/ painful swallowing
constipation
jaundice (yellow skin)
pain with bowel movement
blood in stool
NONE
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36
Have you ever had a colonoscopy
*
This field is required.
yes
no
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37
Have you ever had an upper endoscopy?
*
This field is required.
yes
no
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38
Immunizations
*
This field is required.
Please indicate if you have been immunized against the following. Mark all that apply. If none, mark “NONE.
hepatitis A
hepatitis B
flu
pneumonia
NONE
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39
Who do you live with?
*
This field is required.
Mark all that apply
alone
parents
spouse/ partner
other
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40
Do you consume alcohol?
*
This field is required.
yes
never
in the past
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41
How often do you consume alcohol?
*
This field is required.
Rare
Occasional
1-2 times/week
2-4 times/week
Daily
Rare
Occasional
1-2 times/week
2-4 times/week
Daily
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42
What is your smoking status?
*
This field is required.
currently (every day)
previous
currently (some days)
never
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43
YOUR MEDICAL HISTORY
*
This field is required.
Please indicate if YOU have had any of the following. Mark all that apply.
abnormal heartbeat / palpitations
diverticulosis
migraines
acid reflux / GERD
emphysema or COPD
osteoporosis
alcohol abuse
esophageal stricture or narrowing
ovarian cancer
anemia
esophageal cancer
pancreatitis
anxiety
fibromyalgia
prostate cancer
arthritis
gallstones
seizure disorder
asthma
glaucoma
skin cancer
barrett's esophagus
gout
staph/ MRSA infection
hearing impairment
sleep apnea
heart disease
stomach ulcer or duodenal ulcer
heart attack
stroke
hemorrhoids
thyroid disease
hepatitis C
treatment with blood thinner
high blood pressure
ulcerative colitis
bleeding disorder
blood clots
breast cancer
celiac disease
chronic constipation
bowel obstruction
none
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44
YOUR MEDICAL HISTORY CONTINUED..
*
This field is required.
Please indicate if
YOU
have had any of the following. Mark all that apply. If
none
, mark NONE
colon or rectal cancer
HIV positive
uterine cancer
colon polyps
Crohn's disease
jaundice/ yellow skin as an adult
dementia
kidney problems
depression
liver failure/ cirrhosis
diabetes
lupus
irritable bowel syndrome
other
NONE
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45
SURGERY
*
This field is required.
Please indicate if
YOU
have had any of the following. Mark all that apply. If
none
, mark "I HAVE HAD NO SURGERIES"
aortic aneurysm repair
heart valve replacement
stomach ulcer
appendectomy
hiatal hernia surgery
tubal ligation
automatic cardiac defibrillator
hip replacement
TURP
back surgery
hysterectomy (partial)
weight loss surgery
brain surgery
hysterectomy (total)
vasectomy
colon surgery
knee surgery
defibrillator
coronary artery bypass graft
pacemaker placement
gallbladder removal
prostate surgery
gastric resection
shoulder surgery
other
I HAVE HAD NO SURGERIES
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46
If you selected other surgery please list here:
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47
Please list any additional conditions, diseases OR diagnoses if not previously listed.
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48
Have any of your first degree relatives had Colon Cancer?
*
This field is required.
yes
no
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49
Have any of your first degree relatives had Colon Cancer? If “yes”, who
*
This field is required.
mother
father
brother
sister
other
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50
Have any of your first degree relatives had Colon polyps?
*
This field is required.
yes
no
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51
Have any of your first degree relatives had Colon polyps? If “yes”, who?
*
This field is required.
mother
father
brother
sister
other
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52
Please indicate if
YOUR FAMILY
has a history of the following
*
This field is required.
If Family history
unknown
, mark UNKNOWN
autoimmune hepatitis
bleeding disorder
blood clots
breast cancer
cancer, other
alcohol abuse
celiac disease
hypertension
stomach cancer
cirrhosis
irritable bowel syndrome
Crohn's disease
diabetes
heart attack
hemachromatosis
hepatitis B
hepatitis C
liver cancer
mental illness
ovarian cancer
pancreatitis
prostate cancer
sickle cell
stroke
tuberculosis (TB)
ulcerative colitis
ulcer disease
uterine cancer
other
NONE
FAMILY HISTORY UNKNOWN
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53
Have you had bloodwork, testing or hospital visit in the last 6-8 months?
*
This field is required.
YES
NO
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54
If yes, where and/or who ordered the testing?
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55
Email
*
This field is required.
example@example.com
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56
Tags
Todo
In Progress
Done
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CDHN Health History Form
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