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General: 704.377.4009
Referring MDs
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Medical History Form: Recall Patients
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Saint Martin
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
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
Email
This field is for validation purposes and should be left unchanged.