ࡱ> #% !" bjbj]W]W ?=?= ?^^8T\D@1 # # #0000000$25~0 #"^ # # #0 0--- #j80- #0---6Lu#R-010@1-6#6--&6- # #- # # # # #00( # # #@1 # # # #6 # # # # # # # # #^ ~:  PATIENT HISTORY AND PHYSICAL FORM Name: Date: Marital Status: Chief Complaint: Date of Birth: CURRENT MEDICATIONS (including Over the counter, Vitamins & Herbal Supplements)MedicationDoseReason MedicationDoseReasonPAST MEDICAL HISTORY( Anemia( Depression( High Cholesterol ( Stomach Ulcer( Arthritis( Emphysema( Kidney Disease( Cancer(s) Type: ( Asthma( Heart Disease( OsteoporosisCurrent Treatment: ( Anxiety( Heart Attack( Pneumonia( Vascular Disease( COPD( Hepatitis( Reflux Disease / GERD( Varicose Veins( Diabetes( High Blood Pressure( Thyroid Disease( Other: ALLERGIESHOSPITALIZATIONS OR SURGERIESProcedureDate ProcedureDateFAMILY HISTORYAliveCause of DeathColon Cancer / PolypsConditions / IllnessesFather FatherMotherBrotherBrotherSisterSisterMaternal GrandmotherMaternal GrandfatherPaternal GrandmotherPaternal GrandfatherChildren:___Boys___Girls___ Healthy SOCIAL HISTORY( Smoke ______packs per day How Long __________ When Stopped ________( Sleep ( Peripheral Vascular Disease( Coffee _________ cups per day ( Sleep Disturbances ( Prostate Disease( Alcohol: Type: ________________ Amount: _____________ ( Sleeping Device ( Rectal Bleeding ( Sleep Apnea ( Sexual/Menstrual Dysfunction ( Other Drugs: ____________  ( Shortness of breath ( Shortness of Breath  ( Snoring ( Shortness of Breath REVIEW OF SYSTEMS(Headache( Irregular Heart Beat( Tremor( Change in Bowel Habits( Fatigue( Chest Pain at Rest( Walking Difficulty( Constipation( Fever( Chest Pain with Exertion( Numbness/Tingling( Diarrhea( Chills( Palpitations( Dizziness( Rectal Bleeding( Weight Gain( Weakness( Seizures( History colon polyps( Weight Loss( Jaundice( Painful Extremities( Family hx. colon cancer( Vision Disturbances( Hiatal Hernia( Leg pain/aching/cramping( Family hx. colon polyps( Wear Glasses/Contacts( Pain After Eating Fatty Foods( Burning/itching of the skin( Last Colonoscopy( Bronchitis( Abdominal Pain( Heavy feeling in legs Date: ( Short of breath/exercise( Difficulty Swallowing( Open wounds or sores( No Previous Colonoscopy ( Cough( Painful Swallowing( Swelling of Feet or Ankles( Anesthesia Complications ( Wheezing( Heart Burn( Ulceration of Feet Explain reaction: ( Heart Murmur( Nausea( Hemorrhoids( Heart Races/Skips a Beat( Vomiting ( Black/Bloody Stools  AUTHORIZATION AND RELEASE To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctors office of any changes in my medical status. Signature Date     Great Lakes Surgical Associates Page 2 Page 1 Jeffrey Schratz, M. D., FACSRobert Hodge, M. 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