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HEALTH HISTORY-TO BE COMPLETED BY PATIENT Medical Problems- Please indicate if you are currently experiencing any of the following: □ Anemia □ Chronic lung disease □ Fibromyalgia □ Irritable bowel syndrome □ Stomach/duodenal ulcer Surgeries/Procedures- Please indicate if you have previously had a surgery or procedure: □ NONE Marital Status: □ Single □ Married □ Divorced If you’ve smoked previously, when did you stop? History of Heart Disease (heart attack, heart failure)? □ Yes □ No who: History of High blood pressure? □ Yes □ No who: History of Diabetes? □ Yes □ No who: History of Crohn’s disease or ulcerative colitis? □ Yes □ No who: Copyright 2009 Advanced Gastroenterology Allergies: NONE Aspirin Morphine Penicillin Sulfa Versed Valium Other:
GI Medications- Please indicate if you are currently taking any of the following: NONE

Other Medications- Please include the STRENGTH & DOSAGE:

Review of Systems- Please indicate if you are currently experiencing the following:
General: □ fevers, □ chills, □ sweats, □ anorexia, □ fatigue, □ malaise, □ weight loss
Eyes: □ blurring, □ diplopia (double vision), □ irritation, □ discharge, □ vision loss, □ eye pain
Ears/Nose/Throat: □ earache, □ ear discharge, □ tinnitus (ringing in ear), □ decreased hearing, □ nasal congestion,
□ nosebleeds, □ sore throat, □ hoarseness, □ dysphagia (difficult swallowing)
Cardiovascular: □ chest pains, □ palpitations, □ syncope (passing out), □ dyspnea on exertion (shortness of breath),
□ orthopnea (shortness of breath when lying down), □ peripheral edema (leg swelling)
Respiratory: □ cough, □ dyspnea (shortness of breath), □ excessive sputum, □ hemoptysis (coughing up blood),
□ wheezing
Gastrointestinal: □ nausea, □ vomiting, □ diarrhea, □ constipation, □ change in bowel habits, □ abdominal pain, □ melena
(black stool), □ hematochezia (rectal bleeding), □ jaundice (yellow skin) □ heart burn
Genitourinary: □ vaginal discharge, □ incontinence, □ dysuria (painful urination), □ hematuria (bloody urination), □ urinary
frequency, □ amenorrhea (no menstruation), □ menorrhagia (heavy menstruation), □ abnormal vaginal bleeding, □ pelvic
pain
Musculoskeletal: □ back pain, □ joint pain, □ joint swelling, □ muscle cramps, □ muscle weakness, □ stiffness, □ arthritis
Skin: □ rash, □ itching, □ dryness, □ tattoo
Neurologic: □ transient paralysis, □ weakness, □ seizures, □ syncope (passing out), □ tremors, □ vertigo

Psychiatric: □ depression, □ anxiety, □ memory loss, □ suicidal ideation, □ hallucinations, □ paranoia
Endocrine: □ cold intolerance, □ heat intolerance, □ polydipsia (excessive thirst), □ polyuria (excessive urination)
Heme/Lymphatic: □ abnormal bruising, □ bleeding, □ enlarged lymph nodes
Allergic/Immunologic: □ urticaria (itching), □ hay fever, □ HIV exposure, □ eczema
Copyright 2009 Advanced Gastroenterology

Source: http://www.agipractice.com/pdf/HP_Form_2010.pdf