The GI Endoscopy Center
Patient History

Primary Care Physician
Do you have any limitations to learning? NONE Learning disability Too Sick
  Memory problems Language barrier
Any cultural/religious requests here at the Center? Yes No if so action
Who do you rely on for emotional support? Spouse Family
  Self Other
Have you had any of the following: (circle answers)
Diabetes Yes No Lung/breathing problems Yes No Kidney disease Yes No
GI disorder Yes No Asthma Yes No Thyroid disease Yes No
Heart disease Yes No Emphysema/COPD Yes No Cancer/__________ Yes No
Irregular heart beat Yes No Auto Immune Disorder Yes No Hepatitis/jaundice Yes No
Heart murmur Yes No Bleeding disorders Yes No Musculoskeletal Yes No
Mitral valve prolapse Yes No Neurological disorders Yes No Prosthetic joints Yes No
Valve replacement Yes No Seizure disorder Yes No Tobacco/__Pks/day Yes No
Pacemaker/Defibrillator Yes No Mental Health disorder Yes No Drink alcohol Yes No
High Blood Pressure Yes No Vision/Hearing loss Yes No Recreational drugs Yes No
Stroke Yes No Glaucoma Yes No Anesthesia problems Yes No
Vascular grafts Yes No Sleep Apnea Yes No Post menopause Yes No
TB :Prod. cough Yes No Weight loss 20lbs/2mon. Yes No Night sweats Yes No
Females: Do you think you may be pregnant? YES No
  Hysterectomy Tubal
Explanation to above:
Past surgeries/hospitalization/procedures:
Do you have a cardiologist? YES No
Name: Date last visit:
ALL MEDICATIONS:including aspirin, anticoagulants, herbs, vitamins, supplements, etc.
Name/Dose/Frequency Name/Dose/Frequency
PAIN: Do you have ongoing pain or discomfort? YES No If yes , describe location:
Pain intensity on a scale of 1(least)-10 (most) Average
What makes your pain better? Worse?
Family Health History (Circle all that apply):
High Blood Pressure Stroke Diabetes Diabetes Heart Disease
Stomach problems Colon Polyps Cancer
Patient Signature: __________________________ Significant other: _____________________
RN Confirming information: ______________________________ 8/10cmh
It is the patient responsibility to give us accurate and current information in order for us to take care of you. If you need assistance upon arrival to the center, please let us know prior to date or on preop phone call.