Recall Medical History Form

• Name*
  First Middle Last
• Name Preference
• Contact Phone Number*
• Secondary Phone Number
• Address*
  Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country
• Who is your GI provider?*
• Who is your referring or primary care provider?*
  If you do not have one, please write “self.”
• What is the name of your referring or primary care provider's office?*
  If no referring or primary care provider office, please write “n/a.”
• Date of Birth*
• Height*
• Weight*
• Pharmacy and Location*
• Pharmacy Phone No.

• Allergies

• Are you allergic to latex?*
  • Yes
  • No
• Please list everything that you are allergic to AND the reaction (ex. hives, rash, etc).*
  If no allergies, please write “None”. Click the “plus” sign to add additional allergies.

  Allergen	Reaction

• Medications

• Please list all of the following: Prescription, Non-Prescription, Vitamins, and Supplements*
  If you do not take any medications, please type “none.” To add medications, click on the “plus” sign.

  Drug Name	Strength	Dose/Frequency	Last Taken

• Medical History

• PAST MEDICAL HISTORY*
  Please check all that apply.
  • Alcoholism
  • Anemia
  • Arthritis
  • Asthma
  • Barrett’s esophagus
  • Cancer
  • Celiac disease
  • Colon polyps
  • Congestive heart failure
  • COPD
  • Coronary artery disease
  • Crohn’s disease
  • Depression/anxiety
  • Diabetes
  • Diverticular disease
  • Emphysema
  • Enlarged prostate
  • Gallstones
  • GERD
  • Glaucoma
  • Headache, migraine
  • Hepatitis/liver disease
  • High blood pressure
  • High cholesterol
  • HIV
  • Irritable bowel syndrome
  • Kidney stones
  • Pancreatitis
  • Parkinson disease
  • Peptic ulcer disease
  • Renal disease
  • Seizure disorder
  • Sleep apnea- CPAP/BPAP
  • Stroke
  • Thyroid disease
  • Tuberculosis
  • Ulcerative colitis
  • Varices, esophageal
  • Other
  • None of these apply
• Type of cancer*
• Type of hepatitis/liver disease*
  • Hepatitis A
  • Hepatitis B
  • Hepatitis C
  • Other
• "Other" explanation*
  Please use this space to identify other type of liver disease.
• Diabetes treatment type:
  • Oral
  • Insulin
• "Other" explanation*
  Please use this space to list past medical history not on the check list.
• Other Information:*
  If none of these apply to you, please choose the “N/A” option.
  • Bleeding disorder
  • Defibrillator
  • Endocarditis
  • Home oxygen
  • Kidney/dialysis
  • Metal prosthesis/artificial joints
  • Mobility problems, wheelchair/artificial limbs
  • MRSA
  • Problems with anesthesia
  • Valve replacement- heart
  • N/A
• PAST SURGICAL HISTORY (Check all that apply): Surgeries/Procedures (Please list ALL that you have had).*
  If you have no surgical history, please check the “N/A” option.
  • Appendectomy (appendix removed)
  • Back surgery
  • Bilateral tubal ligation
  • Blood transfusion
  • CABG
  • Cardiac pacemaker
  • Cholecystectomy (gallbladder removed)
  • Colectomy
  • Colonoscopy
  • Coronary stents
  • EGD (upper endoscopy)
  • ERCP
  • EUS
  • Flexible sigmoidoscopy
  • Gastric bypass
  • Hernia repair
  • Hip replacement
  • Hysterectomy
  • Knee replacement
  • Liver biopsy
  • Mastectomy
  • Small bowel resection
  • Thyroidectomy
  • Tonsillectomy
  • TURP
  • Vasectomy
  • Other
  • N/A
• Appendectomy- Please list the year performed.
• Back Surgery- Please list the year performed. Indicate right or left side where applicable. (ex. Right knee replacement in 2005):
• Bilateral tubal ligation- Please list the year performed. Indicate right or left side where applicable. (ex. Right knee replacement in 2005):
• Blood transfusion- Please list the year performed.
• CABG- Please list the year performed. Indicate right or left side where applicable. (ex. Right knee replacement in 2005):
• Cardiac pacemaker- Please list the year performed. Indicate right or left side where applicable. (ex. Right knee replacement in 2005):
• Cholecystectomy- Please list the year performed. Indicate right or left side where applicable. (ex. Right knee replacement in 2005):
• Colectomy- Please list the year performed. Indicate right or left side where applicable. (ex. Right knee replacement in 2005):
• Colonoscopy- Please list the year performed.
• Coronary stents- Please list the year performed. Indicate right or left side where applicable. (ex. Right knee replacement in 2005):
• EGD- Please list the year performed.
• ERCP- Please list the year performed. Indicate right or left side where applicable. (ex. Right knee replacement in 2005):
• EUS- Please list the year performed.
• Flexible sigmoidoscopy- Please list the year performed. Indicate right or left side where applicable. (ex. Right knee replacement in 2005):
• Gastric bypass- Please list the year performed. Indicate right or left side where applicable. (ex. Right knee replacement in 2005):
• Hernia repair- Please list the year performed. Indicate right or left side where applicable. (ex. Right knee replacement in 2005):
• Hip replacement- Please list the year performed. Indicate right or left side where applicable. (ex. Right knee replacement in 2005):
• Hysterectomy- Please list the year performed.
• Knee replacement- Please list the year performed. Indicate right or left side where applicable. (ex. Right knee replacement in 2005):
• Liver biopsy- Please list the year performed. Indicate right or left side where applicable. (ex. Right knee replacement in 2005):
• Mastectomy- Please list the year performed. Indicate right or left side where applicable. (ex. Right knee replacement in 2005):
• Small bowel resection- Please list the year performed. Indicate right or left side where applicable. (ex. Right knee replacement in 2005):
• Thyroidectomy- Please list the year performed. Indicate right or left side where applicable. (ex. Right knee replacement in 2005):
• Tonsillectomy- Please list the year performed. Indicate right or left side where applicable. (ex. Right knee replacement in 2005):
• TURP- Please list the year performed. Indicate right or left side where applicable. (ex. Right knee replacement in 2005):
• Vasectomy- Please list the year performed.
• Other- Please list the year performed. Indicate right or left side where applicable. (ex. Right knee replacement in 2005):

• Other Information

• Employment
  • Employed
  • Self-employed
  • Homemaker
  • Student
  • Retired
  • Disabled
• Occupation
• Employer
• Birthplace
• Education
  Please choose the highest level of education you completed.
  • No formal education
  • Did not finish high school
  • GED
  • High school
  • Vocational qualification
  • Bachelor’s degree
  • Master’s degree
  • Doctorate or higher
• Marital Status
  • Single
  • Married
  • Separated
  • Divorced
  • Widowed
• Spouse/Significant Other's Name (if applicable)
• Please check all statements that apply to you.*
  • None of these statements apply to me.
  • I have children.
  • I use caffeine.
  • I drink alcohol.
  • I currently smoke tobacco.
  • I am a former tobacco smoker.
  • I use smokeless tobacco.
  • I formerly used smokeless tobacco.
  • I have tattoo(s).
  • I have body piercings.
  • I have dentures.
  • I have partials.
  • I have loose/missing teeth.
  • I use corrective lenses.
  • I have hearing aids.
  • I have communication barriers (ex. language or speech: slurred, aphasic
  • I’ve had a recent blood transfusion.
  • I have recently traveled (domestic or international).
• How many children?

  Sons	Daughters

• Caffeine Use:

  Type	Amount

• Alcohol Use:

  Type	Frequency	Amount

• Years Smoked:
  Please enter a value between 0 and 100.
• Ever tried to quit?
  • Yes
  • No
• Age quit:
  Please enter a value between 1 and 120.
• Smoked Tobacco Use:

  Type	Amount	Frequency

  ex. Cigarettes, 1 pack, daily
• Years Used:
  Please enter a value between 0 and 100.
• Ever tried to quit?
  • Yes
  • No
• Age quit:
  Please enter a value between 1 and 120.
• Smokeless Tobacco Use:

  Type	Amount	Frequency

  ex. Snuff, 1 can, per week
• Please explain your communication barriers.

• Family History

• Mother
  • Alive
  • Deseased
• Mother's current age
• Mother's age when she passed
• Father
  • Alive
  • Deseased
• Father's current age
• Father's age when he passed

• GI Family History

• Please indicate if your immediate family members (mother, father, sister, brother) have any of the following:*
  • Barrett’s esophagus
  • Colon cancer
  • Celiac disease
  • Colitis
  • Colon polyps
  • Crohn’s disease
  • Diverticular disease
  • Gallbladder disease
  • Irritable bowel syndrome
  • Liver disease
  • Peptic ulcer disease
  • Ulcerative colitis
  • Esophageal cancer
  • Pancreatic cancer
  • Stomach cancer
  • Liver cancer
  • Genetic cancer conditions
  • None of the above
• Barrett's esophagus*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Colon cancer*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Colitis*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Colon polyps*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Crohn's disease*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Diverticular disease*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Gallbladder disease*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Irritable bowel syndrome*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Liver disease*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Liver disease explanation:
• Peptic ulcer disease*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Ulcerative colitis*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Esophageal cancer*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Pancreatic cancer*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Stomach cancer*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Liver cancer*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Genetic cancer conditions*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister

• Other Family History

• Please indicate if your immediate family members (mother, father, sister, brother) have any of the following:*
  • Alcoholism
  • Alzheimer’s disease
  • Arthritis
  • Asthma
  • Blood disorder
  • Cancer (other than one previously listed)
  • Coronary artery disease
  • High cholesterol
  • Genetic disease
  • High blood pressure
  • Diabetes
  • Cardiovascular disease
  • Migraines
  • Obesity
  • Osteoporosis
  • Kidney disease
  • Seizure disorder
  • Stroke
  • Thyroid disorder
  • Other
  • None of the above
• Alcoholism*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Alzheimer's disease*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Arthritis*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Asthma*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Blood disorder*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Cancer*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Cancer explanation:
• Coronary artery disease*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• High cholesterol*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Genetic disease*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• High blood pressure*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Diabetes*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Cardiovascular disease*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Migraines*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Obesity*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Osteoporosis*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Kidney disease*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Seizure disorder*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Stroke*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Thyroid disorder*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• Other*
  Please check all that apply.
  • Mother
  • Father
  • Brother
  • Sister
• "Other" explanation:
• List
• Comments
  This field is for validation purposes and should be left unchanged.

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