EGD Colonoscopy Colonoscopy prep Flexible Sigmoidoscopy ERCP Liver Biopsy Capsule endoscopy Gerd & Ulcer treatment IBS treatment IBD treatment Hepatitis C treatment Download pdf from welcome Package Please complete the following questions to help us guide your treatment.   Patient Name: Current Gastrointestinal Problems: Colon cancer screening History of polyps Abdominal pain Gas and Bloating Alternating Constipation and Diarrhea Constipation Diarrhea Nausea Vomiting Weight loss Black stools Blood in your stools Blood in the toilet bowl Blood on the tissue paper Anemia Heartburn/Reflux Difficulty swallowing/Food getting stuck Chest pain Abnormal liver tests Hepatitis C Abnormal Xray Other Symptoms: Fever Chills Fatigue/Feeling tired Cough Shortness of breath Swelling of legs Heart palpitations Chest pounding Back pain Joint pain Mouth sores Skin rashes or lesions Blurred or double vision Ringing in ears/Hearing loss Muscle weakness Numbness Frequent headaches/Migraines Dizziness Burning or pain with urination Urinary accidents Anxiety Depression Your Medical History High blood pressure (even if on medication) High cholesterol (even if on medication) Congestive heart failure Heart Attack Bypass surgery Stent placement/Heart catheterization Heart murmur Mitral valve prolapse Asthma Bronchitis Emphysema COPD Pneumonia Tuberculosis Diabetes Thyroid problems Arthritis Seizures Depression Anxiety Stroke or Mini-strokes (TIA) Cancer (list what kind) Have you ever been told you need antibiotics before any kind of dental procedure? Yes No List ALL of your medications below: Do you have any allergies to any medications? Penicillin Sulfa IV dye Latex Other Do you take any herbal medicines? Yes No If yes, list them: Do you take any pain medicines? Motrin Naproxen Advil Celebrex Aleve Other Do you smoke cigarettes? Yes No If yes, how much per day? 1/4 pack 1/2 pack 1 pack 2 packs If you quit smoking, when did you quit? Do you drink alcohol? (including beer, wine, and liquor) Yes No If yes, do you drink: Rarely Occasionally Weekends Daily Do you use IV drugs? Yes No Do you snort cocaine? Yes No List ALL of your surgeries Family History Colon cancer Breast cancer Colon polyps Pancreatic cancer Liver cancer Diabetes Heart disease Other cancers:     Powered by: www.dotsandcoms.us Copyright © 2008, GI Consultants | All Rights Reserved