Gastroenterology Patient History Form

First Name

Last Name

Gender Assigned at Birth

Birth Date

Street Address

City

State

Zip Code

Email Address

Phone Number

Medicare Number

Medicaid Number

Primary Insurance

Primary Insurance Company

In which state is the Wellmark/Blue Cross Blue Shield insurance issued?

Member/Policy Number

Group Number

Employer Issuing Insurance

Subscriber Name

Subscriber Birth Date

Company Phone Number

Phone Number for Preauthorization

Street Address

City

State

Zip code

Emergency Contact

Person to Notify

Relationship

Address

Phone Number

Medical History

Date of last physical exam

Primary care provider

Referring physician

Physician Address

Family History

Do you have any blood family member who have had gastrointestinal conditions?

YesNoUnsure

Family member

NOTE: If you have multiple family members, please select 'add another response' below.

Name of relative:

Relationship:

Sex Assigned at Birth

Diagnosed condition(s)

Colon cancerPolyps Cirrhosis of the liver Colitis Crohn’s diseaseEarly onset heart diseaseCeliac sprue

Is this person still living?

YesNo

Current age

Current health status

Age of death

Cause of death

Personal Habits

Please indicate the details of your personal habits below.

Tobacco

Yes, I currently use tobaccoYes, I have previously used tobaccoNo

How many years have you smoked/used tobacco products?

How many years did you smoke/use tobacco products??

How many years since you quit?

What type of tobacco products do you use?

CigarettesPipeCigarsSmokeless

What type of tobacco products did you use?

CigarettesPipeCigarsSmokeless

Packs a day:

Caffeine

YesNo

What type of caffeine do you consume?

CoffeeTeaPopOther

Other, please specify:

How many cups of coffee do you drink per day?

How many cups of tea do you drink per day?

How many cups of pop do you drink per day?

How many cups of other caffeinated beverages do you drink per day?

Alcohol

YesNo

What is your average daily or weekly consumption?

Have you had previous heavy alcohol usage?

YesNo

IV or recreational drugs

Yes, I currently use IV or recreational drugsYes, I have previously used IV or recreational drugsNo

Medications

Do you routinely use the following nonprescription medication? If so, please bring these with you to your appointment.

AspirinIbuprofenNaproxenKetoprofenAntacidsCimetidine/TagametPepcidZantacAxidNone of the aboveIf you do not use any of these, please select 'none of the above'.

Medical conditions

Do you have any of the following medical conditions?

High blood pressureHeart disease/murmur/valve diseasseDiabetesThyroid diseaseSeizuresAsthma/emphysema/TBBleeding disorder/easy bleeding/bruisingKidney diseaseCancerUlcerColitisHepatitis/jaundiceInternal bleedingStrokeAnemia/blood disorderAnxiety/depressionOtherNone of the aboveIf you do not use any of these, please select 'none of the above'.

Other, please specify:

Have you recently experienced any of the following?

Chest pain YesNo	Shortness of breath YesNo
Abdominal pain YesNo	Heartburn YesNo
Swallowing problem YesNo	Change in bowel habits/diarrhea/constipation YesNo
Bloody/tarry stool YesNo	Jaundice YesNo
Fever/chills YesNo	Weight loss/anorexia YesNo
Vomiting/nausea YesNo	Generalized itching YesNo

Describe briefly the problem for which you have been referred.

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