Microsoft word - pt health questionare.doc

ANUBHA SINHA, M.D.
Hunterdon Digestive Health Specialist
Location 1: 170 Route 31 Flemington, NJ 08822 Patient Health Questionnaire
Please fill out as much as possible to help with your medical care. Use the back of the sheet if you
run out space. For medications, please include the dosage.
Date: ___________ Patient Name: ________________________________________
Date of Birth: _____/_____/_____ Marital Status: _________
Primary Doctor: _____________________________________________
Referring provider: ___________________________________________
**REASON FOR VISIT: ** _______________________________________
Past/Present Gastrointestinal Illnesses (Please circle)
Anemia

Diverticulitis
Hepatitis B
Diverticulosis
Hepatitis C
Duodenal Ulcer
Irritable Bowel Syndrome
Cirrhosis of the Liver
Fatty Liver
Lactose Intolerance
Gallstones
Pancreatitis
Colon Cancer
Gastric Cancer
Colon Polyps
Gastric Polyp
Stomach Ulcer
Chron’s Disease
H. Pylori
Ulcerative Colitis
Depression
Hepatitis A

Do you Smoke? Yes / No **If yes, how many packs per week? __________
Do you Drink Caffeine? Yes / No **If yes, how many drinks per week? ________
Do you Drink Alcohol? Yes / No **If yes, how many drinks per week? ________
Past Surgeries (Examples: Heart bypass, appendectomy etc)
Medication Allergies OR LATEX(please state drug and the reaction)
Medications
(please include all medications including over the counter medicines. Include dosing
information)

Medication
frequency

*Are you on blood thinners? IE Coumidin, Lovenox, Aspirin, Plavix, or Other.

Do you have a history of endocarditis or artificial heart valve? Yes / No

Do you have a pacemaker? Yes / No
If yes, Cardiologist

Do you have a history of kidney problems? Yes / No
Do you have any other serious medical problems for which you currently being treated? Yes / No

Family History (any stomach, colon, liver disease or cancer)
Please Circle
Colitis
Heart Trouble
Colon Cancer
Liver Cancer
Colon Polyps
Liver Disease
Chron’s Disease
Pancreatic Cancer
Esophageal Cancer
Stomach Cancer
Gall Bladder Disease
Ulcer Disease
OTHER__________
Review of Systems:
Please circle any symptoms that you currently have or have suffered
from in the past.
General
Weight loss

Gastrointestinal:
Heartburn

Cardiovascular:
Chest pain

Pulmonary:
Chronic cough

Skin:
Rash

Musculoskeletal:
Joint pains/swelling
Stiff joints
Back pain
Sciatica
Ears, Nose and Throat:
Hearing loss

Hematological:
Easy bruising

Psychiatric:
Abnormal sleep

Neurological:
Headaches

Other symptoms:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Source: http://www.sinha.mdwww.sinha.md/client_files/file/pt-health-questionare.pdf

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