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Patient's Medical Form

Full Name Date of Birth
(dd/mm/yy)		 Age
Reason for today's visit:
When
Height Weight Today's Date
YOUR MEDICAL HISTORY!
      Who? (mother, father, sister, brother)
Alcoholism Yes      No
Anemia Yes      No
Arthritis Yes      No
Asthma Yes      No
Bleeding Tendency Yes      No
Bone / Joint Disease Yes      No
Cancer / Tumor Yes      No
Colitis Yes      No
Congential Heart Yes      No
Crohn's Disease Yes      No
Diabetes Yes      No
Diverticulosis Yes      No
Emphysema Yes      No
Epilepsy Yes      No
Glaucoma Yes      No
Gonorrhea, Syphilis Yes      No
Hay Fever Yes      No
Heart Attack Yes      No
Heart Disease Yes      No
Hermorrhoids Yes      No
Hypertension Yes      No
Jaundice Yes      No
Kidney Disease Yes      No
Liver Disease Yes      No
Nervous Illness Yes      No
Migraine Yes      No
Pneumonia Yes      No
Psychiatric History Yes      No
Rheumatic Fever Yes      No
Stomach Ulcers Yes      No
Stroke Yes      No
Tuberculosis Yes      No
GASTROINESTINAL
Abdominal Pain Yes      No Diarrhea Yes      No
Abdominal Tension Yes      No Gas Yes      No
Poor Appetite Yes      No Indigestion / Heartburn Yes      No
Black Tarry Stool Yes      No Nausea Yes      No
Bowel Habit Changes Yes      No Rectal Bleeding Yes      No
Constipation Yes      No Vomiting Yes      No
OPERATIONS / SURGEY
  Yes      No When Where
Gall Bladder
Stomach
Kidney
Colon
Hysterectomy / Ovary
Appendix
Other
Have you ever had any of the following?
  Date? What Facility?
Barium Swallow
Upper GI series
Barium enema
Ultrasound
CT/MRI abdomen / pelvis
Have you had any recent blood work?
What Kind? Date What Facility?
Have you had any stool euflores?
What Kind? Date What Facility?
Have you ever had any of the following?
  Date? What Facility?
Endoscopy
Colonoscopy
ERCP
Liver Bx
      Number Per Day How many years?
Use Tobacco?
Drink Alcohol?
Drink Coffee?

Race or nationality of parents:

Have you lived outside or traveled outside the US? (if so when and where?)

Have you received any blood transfusions? (if so when)

Please list all Allergies to medication or other substances:

Please list all of your current medication and dose:

This section is for your family history
      Who? (mother, father, sister, brother)
Alcoholism Yes      No
Anemia Yes      No
Arthritis Yes      No
Asthma Yes      No
Bleeding Tendency Yes      No
Bone / Joint Disease Yes      No
Cancer / Tumor Yes      No
Colitis Yes      No
Congential Heart Yes      No
Crohn's Disease Yes      No
Diabetes Yes      No
Diverticulosis Yes      No
Emphysema Yes      No
Epilepsy Yes      No
Glaucoma Yes      No
Gonorrhea, Syphilis Yes      No
Hay Fever Yes      No
Heart Attack Yes      No
Heart Disease Yes      No
Hermorrhoids Yes      No
Hypertension Yes      No
Jaundice Yes      No
Kidney Disease Yes      No
Liver Disease Yes      No
Nervous Illness Yes      No
Migraine Yes      No
Pneumonia Yes      No
Psychiatric History Yes      No
Rheumatic Fever Yes      No
Stomach Ulcers Yes      No
Stroke Yes      No
Tuberculosis Yes      No

Is there any colon/intestinal cancer?(Yes/No) or Polyps? Yes/No) in your family?

If yes, in which family member?

Is there any other information you want the doctor to know or are there any questions you may want the doctor to answer?

   











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1312 West Main Street • Waterbury, CT 06708 • 203.756.6422

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