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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:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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