Mustafa Kamal

Metropolitan Gastroenterology Assoc. MEDICAL & FAMILY HISTORY FORM Name: ____________________________________________________________________ Today's Date: ____________________________________ Date of Birth: ________________________________________________ Height: ___________________________ Weight: ___________________ Referring Physician: ______________________________________________ Reason for Visit:_____________________________________________ Pharmacy:_______________________________ Address:_________________________________________________ Phone: __________________ ALLERGIES None Versed Sulfa Aspirin Codeine Demerol Penicillin IV Contrast or iodine Latex Eggs Nuts Other Allergies: __________________________________________________________ Propofol/Diprivan Gastrointestinal Cancer General PAST OR PRESENT MEDICAL CONDITIONS None Anemia Cataracts Emphysema Thyroid disease Blood transfusion(s) Glaucoma None Cervical/Uterine cancer Esophageal cancer None Celiac sprue Crohn’s disease Irritable bowel syndrome Hemorrhoids Pancreatitis Blood clotting problems Heart attack Pneumonia Convulsions/Seizures Anxiety disorder Gout High blood pressure Sleep apnea Cardiac arrhythmia Stroke Asthma Diabetes Kidney disease Back problems Depression Arthritis Other General Conditions: _____________________________ Breast cancer Liver cancer Colon cancer Lung cancer Prostate cancer Other Cancer: ______________________ Acid reflux/Heart burn Peptic ulcer disease Diverticulitis Diverticulosis Gallstones Cirrhosis of liver Hepatitis A Hepatitis B Other GI Conditions:________________________________________ Ulcerative colitis Colon polyps Other liver disease Hepatitis C PREVIOUS SURGERIES ▪ PROCEDURES ▪ HOSPITALIZATIONS None Tonsils date: __________ Cardiac bypass date: __________ Breast date: __________ Tubal ligation date: __________ ERCP date: __________ Appendix removal date: __________ Heart valve replacement date: __________ Gastric bypass/Surgery date: __________ EGD date: __________ Prostate date: __________ C‐section date: __________ Gall bladder removal date: __________ Sigmoidoscopy date: __________ Joint surgery date: __________ Hysterectomy date: __________ Colon resection date: __________ Colonoscopy date: __________ Implanted defibrillator (ICD) date: __________ Ovary removal date: __________ Colostomy date: __________ Capsule endoscopy date: __________ Other (please include dates): _________________________________________________________________________ SOCIAL HISTORY Occupation: _____________________________________ Single Married Divorced Civil union Other: ________________________________ Number of Children: ___________ Separated Widowed ‐‐‐‐‐‐ Alcohol Consumption ‐‐‐‐‐‐ None Beer Liquor qty.: __________ frequency: ___________ qty.: __________ frequency: ___________ Wine Prior history of >10 drinks/week qty.: __________ frequency: ___________ qty.: __________ frequency: ___________ ‐‐‐‐‐‐ Tobacco and Drug Use ‐‐‐‐‐‐ Current everyday smoker Current some day smoker qty.: __________ frequency: ___________ Cigarettes qty.: __________ frequency: ___________ Cigars Other: _____________ qty.: __________ frequency: ___________ No drug use Recreational drug user Former smoker Never smoked M EDICATIONS Name of Medication Strength How Often Name of Medication Strength How Often FAMILY HISTORY Deceased at age Cause of death Mother Father Sister Brother Daughter Son Grandmother Grandfather _____ _________ _____ _________ _____ _________ _____ _________ _____ _________ _____ _________ _____ _________ _____ _________ Bile duct cancer Bladder cancer Breast cancer Colitis Colon cancer Colon polyps Crohn’s disease Esophageal cancer Female organ cancer Heart problems Liver disease Pancreatic cancer Skin cancer Small intestine cancer Stomach cancer REVIEW OF SYSTEMS Please indicate if your are experiencing, or have experienced in the last six (6) months: Cardiovascular Irregular heart beat Palpitations Passing out Angina/chest pressure with activity Ankle swelling Constitutional Weight gain Weight loss Fever Ear Nose Mouth and Throat Nose bleeds Eye pain Change in vision Dry eyes Bleeding gums Hoarseness Mouth sores Endocrine Excessive thirst Cold intolerance Respiratory Chronic cough Shortness of breath Gastrointestinal Abdominal pain Black stool Change in bowel habits Constipation Diarrhea Gas Heartburn Jaundice Nausea Vomiting Belching Bloating Blood in stool Incontinence to stool Loss of appetite Milk intolerance Trouble swallowing Pain with bowel movement Painful swallowing Rectal bleeding Genitourinary Frequent urinary infections Blood in urine Urinary incontinence Save As Print Form Hematologic/Lymphatic Prolonged bleeding Enlarged glands Use of Plavix, Coumadin or other blood thinners Integumentary Itching Rashes Musculoskeletal Back pain Joint pain Muscle pain Neurological Seizures Headaches Stroke or paralysis Psychiatric Anxiety Depression Memory loss Reset Form