Lincolngi.com

LINCOLN SURGERY ENDOSCOPY SERVICES
Patient Name:_________________________________________ Your Family Doctor is:___________________________
Reason for today's exam:
Height: ________ Weight: _________
Please list all medications, including over-the-counter and herbal remedies below.
Medicine
Why Taking
Medicine
Why Taking
**List all ALLERGIES including type of allergy reaction: (example: Sulfa-Rash)
**Do you take any of the following Anticoagulants? (Circle) Yes No
Coumadin Plavix Heparin Xarelto Pradaxa Eliquis LAST TAKEN_________
**Do you take any NSAIDS and/or Arthritis medications? (Circle) Yes No
Aspirin Ibuprofen/Advil Aleve/Naproxen Excedrin Toradol
Alka Selzer Bextra Celebrex Relafen Feldene Vioxx
Indocin Lodine Mobic Other _______________ LAST TAKEN____________
**Do you take any of the following MAO inhibitors? (Circle) Yes No
Azilect/Rasagiline Marplan/Isocarboxazid Nardil/Phenelzine
Parnate/Tranylcypromine Eutonyl Eldepryl/Emsam/Zelapar/Selegine
Do you have or have you had in the past? (Please CIRCLE all that pertain)
DIGESTIVE SYSTEM
Heart Disease/Problems
Rectal Bleeding/Blood in Stools
Heart Attack Year_______
Abdominal Pain
Rhythm Problem/Irregular Heart Beat
Recent Change in Bowel Habits
High Blood Pressure
Unintentional Weight Gain____ or Loss____
Low Blood Pressure
Nausea or Vomiting
Pacemaker or Defibrillator
Heartburn
History of Stroke/TIA
Difficulty Swallowing/Food Getting Caught
Other________________________________________
Hepatitis
RESPIRATORY/LUNGS
Crohns or Ulcerative Collitis
Breathing or Lung Problems
Other____________________________________________
NERVOUS SYSTEM
COPD/Emphysema
Seizures
Sleep Apnea
Muscle Weakness/Tingling (Location)_______________
Shortness of Breath
Nerve Injury or Paralysis
Currently Smoke _________Amount daily
Back or Neck Problems
Other_________________________________________
Other____________________________________________
Please see reverse side for more questions.
Rev. 9/13, 8/13 (barcode only), 6/13, 11/12, X:\LS Endoscopy Services\Forms\GI Chart Forms\Health History 5/12 (title only), 9/09, 5/09, 10/07, 4/07 LINCOLN SURGERY ENDOSCOPY SERVICES
INFECTIONS
Bleeding or Clotting Disorders
Diabetic
Kidney Problems
ORAL CAVITY
Thyroid Problems
Wear Dentures
History of Recreational Drug Use
Partial Plate
Alcohol Use How Often______________________
Loose Teeth
Glaucoma-Narrow Angle
Difficulty Opening Mouth
FEMALE PATIENTS
History or Current Cancer
Currently Pregnant
Location___________________________________
Currently Breast Feeding
Is there any other pertinent information that we need to know? If so please list below
Please list past surgeries and approximate year performed:
Have you ever had this or any of the following tests before? Please state approximate year.
_____Colonoscopy
_____Flexible Sigmoidoscopy (Flexi)
_____Upper Gastrointestinal Endoscopy (EGD)
_____Esophageal Dilation
Were there any problems?________________________________________________________________________
Because of sedation, you will not be able to drive or return to work for the remainder of the day.
Who will be driving you home following your procedure?_____________________________________________
(If your procedure does not involve sedation please disregard above.)
Do you have and Advance Directive (Living Will/Power of Attorney for Healthcare)? Yes_____ No_____
The information I have provided is accurate to the best of my knowledge.
Patient Signature:________________________________________
Reviewed by:______________________________________________
Advance Directive on chart ____ yes ____ no Please see reverse side for more questions.
Rev. 9/13, 8/13 (barcode only), 6/13, 11/12, X:\LS Endoscopy Services\Forms\GI Chart Forms\Health History 5/12 (title only), 9/09, 5/09, 10/07, 4/07

Source: http://www.lincolngi.com/Health_History_Questionnaire.pdf