Charles River Endoscoy Patient medical history form

Pre-Procedure Medical Form      Please Circle all yes answers

Name: _____________________________        Procedure: _________________________________         Reason for Procedure:________________________

Doctor: ____________________________________

Please circle all Yes answers                                                                                           

  Immune problems: Yes/ No  Type: ________________     Do you have cancer: Yes/ No Type: _______________       

  Yes/No  Do you have difficulty climbing up stairs?    

 Cardiac Problems:                                                                                                                                                                 

  High Blood Pressure:   Yes/No    Valve Replacement Yes/No:  Date of surgery:_______   Heart Murmur/Palpitations/ Arrhythmias Yes/No

  Chest pain/Heart Attack; Yes/No   Date: ___________    Pacemaker Yes/No  Date of placement: ___________Last Date Tested: _____________

   Pacemaker with a Defibrillator:  Yes/No   Bypass or angioplasty; Yes/No  Date of surgery: _____     Swelling of Extremities:Yes/No

   Irregular heart rate/ Atrial Fibrillation (Afib) Yes/No     Have you ever had a stress test? Yes/No

 Respiratory Problems:                                                                                                          

Asthma/ COPD/ Emphysema   Yes/No         Sleep Apnea; Yes/No   Type of device: ____________           Do you snore?  Yes/No     

Tuberculosis:  Yes/No           Smoke (now/ past);Yes/No  Amount: ____________                             _                                                             

Liver/Gallbladder Problems:                                                      

Hepatitis:  A   B   C    Yes/No             Cirrhosis/Liver Disease Yes/No                Gallbladder Disease/Surgery  Yes/No                                            

Recreational Drug Use; Yes/No Type: ____________                 Alcohol Use; Yes/No  Amount:                                                                                                      

Neurological Problems                                                                                                                                                                          

Stroke    Yes/No         Seizure  Yes/No         Headache Yes/No          Dizziness  Yes/No          TIA  Yes/No                 

 Active shingles  Yes/No               Glaucoma Yes/No

Blood Disorders:                     

Anemia Yes/No                Clotting / Bleeding disorders Yes/No        Bruising  Yes/No:       Active MRSA infection Yes/No       HIV/ AIDS Yes/No

Endocrine Problems:

Thyroid problems Yes/No                     Diabetes Yes/No Insulin__ Oral__ Diet controlled__

Orthopedic Problems:

Limitation of movement; Yes/No Where: ___________         Joint Replacement Yes/No  what joint______________________

Metal pins, rods, plates: Yes/No           Body piercings Yes/No


Depression/ Anxiety/ Panic Disorders Yes/No      Confusion/ Developmental Delays   Yes/No           Bipolar/ Schizophrenia Yes/No             

Kidney/Prostate Problems

Kidney Failure/ Kidney Stones Yes/No      Urinary Incontinence Yes/No

Men Only:

 Prostate Enlargement   Yes/No           Prostate Cancer Yes/No                         Other:  

Women Only:

Hysterectomy  Yes/No        Mastectomy/Lumpectomy R   L   Yes/No             Are you pregnant? Yes/No  N/A ___   

Date of last menstrual period: ______________

GI Problems: 

Family History of Colon Cancer Yes/No       Relationship: ________________________________   Personal History of Colon Cancer   Yes/No    

Family History of Colon Polyps  Yes/No      Relationship: ________________________________     Personal History of Colon Polyps  Yes/No

Diverticulosis/Diverticulitis  Yes/No       Colitis/Crohns Irritable Bowel Syndrome  Yes/No:       Bleeding/ Hemorrhoids Yes/No:    

Constipation/Diarrhea  Yes/No   Stomach Ulcers Yes/No      Barrett’s Disease  Yes/No        Esophageal Strictures/Choking Yes/No        Acid Reflux  Yes/No

Trouble swallowing/ food sticking   Yes/No            Weight Loss/Nausea/Vomiting    Yes/No