Medical History Questionnaire

The Office of Dr. Vivian Asamoah

25230 Kingsland Blvd., STE 101

Katy, TX 77494

P: 281-746-9284
Please complete the Medical History questionnaire below.
Today's Date:*

MonthDayYear
Date
Patient Name:*
Please enter full name
Date of Birth*

MonthDayYear
How did you hear about us/Referring physician:
Best Contact Number*

Area CodePhone Number
My heightheight* My weight weight*
Are you scheduling for a routine or (preventative) colonoscopy?

Yes I wish to schedule for a routine or (preventative) colonoscopyNo, I'm being seen for another reason
Reason for Today's Visit: *
Gastrointestinal Symptom Review
Are you experiencing unexplained weight loss?*

YesNoSometimes
Having Fever or Chills?*

YesNoSometimes
Having Nausea?*

YesNoSometimes
Vomiting Regularly?*

YesNoSometimes
Having HeartburnSymptoms ?*

YesNoSometimes
Having Difficulty Swallowing ?*

YesNoSometimes
Bothered by Abdominal Pain or Swelling ?*

YesNoSometimes
Having Abdominal Pain or Discomfort ?*

YesNoSometimes
Constipated?*

YesNoSometimes
If yes, How many bowel movements a week?
Having Diarrhea?*

YesNoSometimes
If yes, how many bowel movements a week?
If yes, do you have diarrhea at night?*

YesNoSometimes
Having any black or tarry stools?*

YesNoSometimes
Seeing red blood during bowel movement?*

YesNoSometimes
Having Hemorrhoid Symptoms?*

YesNoSometimes
Have you ever had Ulcers?*

YesNo
Have You Had an Inflammatory Disease of the Small Bowel or Colon?*

YesNoSometimes
Have You Had Gallstones?*

YesNoSometimes
Have You Had Pancreatic Problems?*

YesNoSometimes
Have You Had Hepatitis of Other Liver Problems?*

YesNoSometimes
Have You Had Gallstones?

YesNoSometimes
Have You Had Pancreatic Problems?

YesNoSometimes
Have You Had Hepatitis ot Other Liver Problems?

YesNoSometimes
If yes, is your liver function currently normal?

YesNoSometimes
Have You Had any Recent Tests?*

LabsUltrasoundCTEGDColonoscopyERCPMRIX-rayNone
If So, When:
Please state year and which test
By whom:
Which provider or facility tests were ordered by or done.
ALLERGIES and REACTION:*
Example: Penicillin - Hives,

SURGERIES and YEAR OF SURGERY *


Type of Surgery/Year
Type of Surgery/Year
Type of Surgery/Year
Type of Surgery/Year

Have you ever had any polyps removed during a colonoscopy?*

	POLYPS?	If you had polyps, how many were removed?
Did your Doctor find polyps?

Did you have any issues with the following:
Pre Procedure Prep*

YesNo
Procedure Anesthesia*

YesNo
During Procedure*

YesNo
Post Procedure Complications*

YesNo
If yes, please briefly describe the problem:
MEDICATIONS LIST: Please list name, dosage and frequency*
Example: Omeprazole 40MG twice daily, Multivitamin Once daily, "None" or "N/A" if none.
MEDICAL HISTORY: Have you been diagnosed with any health problems?*
Example: "2008 -Hypertension" or "None" or "N/A" if none.
SOCIAL HISTORY

Provide details regarding current and/or past use of the following
ALCOHOL (Beer, Wine, Liquor)*

YesNo
No, If yes, How often?
How many drinks?
IV or RECREATIONAL DRUGS*

YesNo
If so, which one:
TOBACCO (Cigarrettes, Cigars, Chewing Tobacco, e-Cigs)*

YesNo
Smoking Status:*

EverydaySomedaysFormerNever
How many?
How often?
CAFFEINE (Coffee, Tea, Sodas, Energy Drinks)*

YesNo
If yes, how many cups a day?
MARITAL STATUS:*

SingleMarriedDivorcedWidowed
FAMILY HISTORY

Has anyone in your family been diagnosed with the following:
Colon Cancer*

YesNo
Relation:
Age at diagnosis
Colon Polyps*

YesNo
Relation:
Age at diagnosis
Celiac Disease*

YesNo
Relation:
Age at diagnosis
Crohn's Disease*

YesNo
Relation:
Age at diagnosis
Ulcerative Colitis*

YesNo
Relation:
Age at diagnosis
Liver Disease*

YesNo
Relation:
Age at diagnosis
OTHER CANCER:*
Relation:
Age at diagnosis
Have you Ever Had any Genetic Testing to Evaluate Risk of Cancer?*

YesNo
Have you had any of the problems below in the past?
*

FeverExcessive SweatingChillsFatigueAppetite changeSinus CongestionSore throatHeadacheNose bleedsHearing LossMouth SoresTrouble SwallowingDental problemHoarsenessNone
*

Chest tightnessWheezingShortness of breathCoughNone
*

Chest PainLeg SwellingPalpitationsNone
*

Joint PainBack painJoint swellingMuscle swellingMuscle weaknessNoneColor ChangeWoundRashItchingNone
*

Swollen lymph nodesBleeds / Bruises EasilyAnemiaNone
*

Difficulty urinatingKidney StonesFlank PainBlood in urineUrinary InconrtinenceDysuria (painful urination)Gait problemsNone
*

DizzinessHeadachesLight-HeadednessNumbnessSeizuresSpeech DifficultyFaintingNeurological WeaknessConfusionNone
*

AgitationBehavioral ProblemSelf-InjuryDecreased concentrationNervous / AnxiousDifficulty SleepingNone
Should be Empty:

FAMILY HISTORY

Have you had any of the problems below in the past?