No está claro cuán grande es el papel de los antibióticos https://antibioticos-wiki.es en las relaciones competitivas entre los microorganismos en condiciones naturales. Zelman Waxman creía que este papel era mínimo, los antibióticos no se forman sino en culturas limpias en entornos ricos. Posteriormente, sin embargo, se descubrió que en muchos productos, la actividad de síntesis de antibióticos aumenta en presencia de otros tipos o productos específicos de su metabolismo.

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ADULT PATIENT HISTORY FORM
Kamini Ramani, M.D., P.C.
Gastroenterology and Internal Medicine
99 E State Street
Gloversville, NY 12078
Telephone: (518) 725-6080.
NAME: ______________________________ DOB: ___/___/___ DATE COMPLETED: ___/___/___ Referred by: (Primary Care Physician’s Name): ___________________________________________ Occupation: _______________________________________ Gender : F_____ M _____ Do you have any children? : N_____ Y_____, How many : ______ Boys _____ Girls______ People in household apart from self : ______________ _______________________________________ What is the main complaint for which you are referred? : ____________________________________ _____________________________________________________________________________________ In general, how would you say your health is : [] Excellent [] Very Good [] Good [] Fair [] Poor GASTROINTESTINAL SYMPTOMS:
Please mark if you ever had any of the fol owing symptoms. [] Trouble swallowing [] Pain after meals PAST MEDICAL HISTORY:
Please check if you have or had the following medical problems. Cancer : ____________________________________________________________________ Site of cancer: ________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
PAST SURGICAL HISTORY:
Please check if you had the fol owing operations: Any other surgeries not listed above:
______________________________________________________________________________
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RECENT HOSPITALIZATION:
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ RECENT TESTING:
Abdominal Ultrasound: ________________________________________________________
Abdominal CT : ______________________________________________________________ Abdominal MRI: ______________________________________________________________ Any other tests:
______________________________________________________________________________
______________________________________________________________________________ ______________________________________________________________________________ COLONOSCOPY: _______________________________________________________________
GASTROSCOPY: ________________________________________________________________
CURRENT MEDICATION LIST:
Check if you're taking the following medications.
[] Coumadin: _____________________________________________________
[] Aspirin: _____________________________________________________ [] Plavix: _____________________________________________________ [] Anti-inflammatory medications like Advil, ibuprofen, Aleve: _______________ [] Lovenox: _____________________________________________________ LIST ALL YOUR MEDICATIONS HERE: Please write name and dosage.
______________________________________________________________________________
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ALLERGIES: Check the drugs you have al ergies to:
[] Penicillin [] Demerol [] Iodine dye [] Sulfa drugs [] Valium / Versed Latex What type of reaction did you have to above medications? : ____________________________ Any other allergies to any other medications: _______________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Are you advised to have antibiotics before (dental) procedures? : Yes / No
Any problems with anesthesia or sedation for prior procedures? : Yes / No
ADVANCE DIRECTIVES
Do you have Advanced Directies: Yes_______No_____________ Please provide a copy Living Will: _______________ Healthcare Proxy: _________ DNR: _______________ VACCINATION
Last Pnumococcal Vaccine: ___________________________________________________ Last Flu shot: ______________________________________________________________ HEALTH HABITS: PERSONAL HISTORY
SMOKING: Do you smoke cigarettes/cigar pipe: Yes________ No________
Amount per day____________________ Per week____________________ Age at onset of smoking________________ Years of smoking___________________ Smokeless Yes_______________ No____________________ Former smoker: Yes: _________________ No: __________________________ How much did you smoke: _______For how long: __________ When did you quit: _________ ALCOHOL: Yes: _________________ No: _____________________
Amount used daily : _____________________ Weekly: ______________________ Have you ever felt that you had a problem with alcohol: Yes ___________ No ____________ Former drinker: Yes _______________ No __________________ How much did you drink: ______ For how long: ____ Date when quit: _____________ Use of recreational drugs: Never_______________ Yes____________________
If yes please list: _______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ Coffee/Tea – Caffeinated soda: Yes_____ No________ How much a day: _____________
FAMILY MEDICAL HISTORY:
Is your Mother alive or deceased? ________________________________________________________________ If alive, please list age and any medical problems. If deceased, please list age at death and any medical problems associated. : ____________________________________________________ Is your Father alive or deceased? ________________________________________________________________ If alive, please list age and any medical problems. If deceased, please list age at death and any medical problems associated. : ____________________________________________________
If you answered yes to siblings - please list how many brothers and/or sisters you have,
whether they are alive or deceased, their ages, and any medical problems. : ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Do you have any children? [] Y [] N ANY FAMILY MEMBERS WITH FOLLOWING DIAGNOSIS AND AGE AT DIAGNOSIS:
Colon polyps ___________________________________________________________________ Colon cancer___________________________________________________________________ Pancreas cancer ________________________________________________________________ Stomach cancer_________________________________________________________________ Colitis/Crohn’s_________________________________________________________________ Liver disease___________________________________________________________________ Pancreatitis ___________________________________________________________________ PLEASE CIRCLE ANY CONDITIONS IN ANY BLOOD RELATIVE:
(INCLUDE PARENTS, BROTHER, SISTER, GRANDPARENTS AND CHILDREN)

Please name the relationship (e.g.) father, sister and the age of onset, if known,
Heart Disease_________ High Blood Pressure________ High Cholesterol__________ Diabetes__________ Emphysema (COPD) ________ Stroke_____________ Asthma____________ Anemia (low blood count) _______ Blood Clots_______ Thyroid problems_______ Breast Cancer _________ Prostate Cancer______ Arthritis_____________ Skin disease____________ Hepatitis_______ Alcoholism____________ Psychological problems (anxiety – depression) _______ Other_________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ REVIEW OF SYSTEM
PLEASE INDICATE THE SYMPTOMS YOU HAVE AT PRESENT: CIRCLE OR MARK IT WITH PEN.

GENERAL :
Anemia____, Excessive hair growth ____, Change in sleep____, Easy bruising ___,
Fatigue____, Weight loss (unexplained) ____, Shakiness____, Hair loss____,
Sweating____, Intolerance to heat/cold ____, Night sweats____, Weight problem__.
SKIN:
Acne____, Eczema____, New lesions/moles____, Change in skin mole____,
Rash____, Skin cancer____, Sensitive to sun____, Nail changes____.
EYES, EARS, NOSE, THROAT :
Blurry vision____, Change in vision____, Glaucoma____,
Ringing in the ears____, Hearing difficulty____, Al ergies/hay fever____,
Sinus infections____, Hoarseness____, Swollen lymph glands____,
Runny nose/congestion____.
RESPIRATORY/LUNG:
Asthma____, Swol en lymph glands____. Excessive Hoarseness____
Cough____, Coughing blood____, Shortness of breath____,
CARDIOVASCULAR/HEART:
Irregular heart beat____, Murmur____, Ankle Swelling____,
Palpitations____, Chest pain/pressure____, Blood clots/phlebitis____,
Cholesterol problem____, Lightheaded spells____,
Mitral Valve Prolapse ____.
GASTROINTESTINAL:
Abdominal distention____, abdominal pain & cramping____, Blood in stool____,
Constipation____, Change in bowel habits/stool____, Diarrhea____,
Difficulty swallowing____, Loss of stool control____, Nausea____,
Excessive gas/bloating____, Heartburn____, Ulcers in the stomach____,
Hemorrhoids____, Jaundice____, Rectal Bleeding____,
Vomiting____, Change in appetite____.
URINARY SYSTEM:
Frequent urination____, Burning on urination____, Infections____, Blood in urine____,
Urgency to urinate____, Urinary hesitancy____, Kidney stones____,
Venereal warts____, Urinary incontinence____, Frequent bladder ______.
GYNECOLOGICAL:
Irregular periods____, Painful periods____, Menopausal concerns____,
Hot flashes____, Infertility____, Vaginal infections____,
Sexual y transmitted disease____.
MUSCULOSKELETAL:
Arthritis____, Back pain____, Gout____, Joint pain/stiffness____,
Leg pain____, Muscle weakness____.
NEUROLOGICAL:
Memory Loss____, Loss of sensation____, Seizures____, Headaches/severe____,
Paralysis____, Tremors____, Dizziness____, Numbness/tingling____.
MENTAL HEALTH:
Difficulty concentrating____, Anxiety____, Chronic fatigue____,
Emotional crying excessively____, Guilty feelings____, Hearing voices____,
Loss of interest in work____, Insomnia____, Loss of sexual drive____,
Feeling of hopelessness____, Nervousness____, Panic attacks____,
Social withdrawal____, Stress, severe____, Thoughts of suicide____,
Depressed mood____, Visual hal ucinations____.
SCREENING FOR DEPRESSION:
Have you often been bothered by feeling down, depressed or hopeless? Yes____ No____
Have you been bothered by little interest or pleasure in doing things? Yes____ No____
SCREENING FOR ALCOHOL USE DISORDER:
When was the last time you had more than four drinks in a day? Never_______ In past 3 months______ Over 3 months ago ____________ Anything else you would like to mentions: ___________________________________________ Reviewed with Patient: _______________________ MD signature: _____________________ Signature : _____________________________________ Print Name : ______________________Date: ___/__/_____

Source: http://www.etechdata.info/kaminiramanidr/5-3ADULT%20PATIENT%20HISTORY%20FORM.pdf