Date
Chart Number
Name
Birth Date
Age
GI Physician
Referred by
Present Problem
Weight
Height
BMI
Pregnant
Yes
No
Preferred Language
Translator Needed
Email Address
Preferred Method of Contact
Personal Health History
Diabetes
Stroke
Cardiac Stents
Heart Failure
Heart Attack
Heart Bypass
Pacemaker
Defibrillator
Heart Catheterization
Irregular Heart Beat
Angina
Blocked Arteries
Heart Valve Replaced
Other
COPD
Emphysema
Asthma
Inhalers
Sleep Apnea CPAP
Home Oxygen
High Blood Pressure
Reflux
Bleeding Disorder
Ulcers
Liver Disease
Hepatitis A/B/C
Cirrhosis/Encephalopathy
Ascites (Fluid in Abd.)
Seizures
Last Seizures
Seizure Stimulator
Parkinson's
Muscular Dystrophy
Alzheimer's
Migraines
Depression
Anxiety
Kidney Disease
Dialysis
Crohn's Disease
Colitis
Joint Replacement
Past Complications with Sedation
Yes
No
List Complications
Fear of Needles
Yes
No
Difficulty Obtaining IVs
Yes
No
Do You Currently Smoke
Yes
No
Number Packs/Day
Former Smoker
Yes
No
Recreational Drugs
Yes
No
Drink Alcohol
Yes
No
Socially
Amount
Immunizations
Flu Vaccine
Yes
No
Pneumonia Vaccine
Yes
No
Covid-19 Vaccine
Yes
No
Booster
Yes
No
Surgeries
Disabilities/Immobility
Colonoscopy
Yes
No
Date
Upper Endoscopy
Yes
No
Date
Mammogram
Yes
No
Date
History of Polyps
Self
Yes
No
Age
Family
Yes
No
Relationship
Age
Personal or Family History of:
(List self or relationship of family member and age)
Colorectal Cancer
Stomach/Esophageal Cancer
Breast Cancer
Kidney/Ureter Cancer
Endometrial/Uterine/Ovarian
Pancreatic/Biliary Cancer
Small Bowel Cancer
Brain/Sebaceous Adenomas
Latex Allergy
Yes
No
Reaction
Allergy to eggs or soybeans
Yes
No
Reaction
Allergies
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Reaction
Reaction
Reaction
Reaction
Reaction
Reaction
Reaction
Present Medications
(List over the counter and Herbal Meds)
Current Pharmacy
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Drug
Dose
Dose
Dose
Dose
Dose
Dose
Dose
Dose
Dose
Dose
Dose
Dose
Dose
Dose
Hx./Medications Reviewed by Endo Nurse