New Patients

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Please complete the following questions to help us guide your treatment.
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Patient Name:
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Current Gastrointestinal Problems:
Colon cancer screening History of polyps Abdominal pain
Gas and Bloating Alternating Constipation and Diarrhea Constipation
Diarrhea Nausea Vomiting
Weight loss Black stools Blood in your stools
Blood in the toilet bowl Blood on the tissue paper Anemia
Heartburn/Reflux Difficulty swallowing/Food getting stuck Chest pain
Abnormal liver tests Hepatitis C Abnormal Xray
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Other Symptoms:
Fever Chills Fatigue/Feeling tired
Cough Shortness of breath Swelling of legs
Heart palpitations Chest pounding Back pain
Joint pain Mouth sores Skin rashes or lesions
Blurred or double vision Ringing in ears/Hearing loss Muscle weakness
Numbness Frequent headaches/Migraines Dizziness
Burning or pain with urination Urinary accidents Anxiety
Depression
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Your Medical History
High blood pressure (even if on medication) High cholesterol (even if on medication) Congestive heart failure
Heart Attack Bypass surgery Stent placement/Heart catheterization
Heart murmur Mitral valve prolapse Asthma
Bronchitis Emphysema COPD
Pneumonia Tuberculosis Diabetes
Thyroid problems Arthritis Seizures
Depression Anxiety Stroke or Mini-strokes (TIA)
Cancer (list what kind)
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Have you ever been told you need antibiotics before any kind of dental procedure?
Yes No
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List ALL of your medications below:
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Do you have any allergies to any medications?
Penicillin Sulfa IV dye Latex Other
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Do you take any herbal medicines?
Yes No
If yes, list them:
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Do you take any pain medicines?
Motrin Naproxen Advil Celebrex Aleve Other
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Do you smoke cigarettes?
Yes No
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If yes, how much per day?
1/4 pack 1/2 pack 1 pack 2 packs
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If you quit smoking, when did you quit?
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Do you drink alcohol? (including beer, wine, and liquor)
Yes No
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If yes, do you drink:
Rarely Occasionally Weekends Daily
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Do you use IV drugs?
Yes No
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Do you snort cocaine?
Yes No
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List ALL of your surgeries
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Family History
Colon cancer Breast cancer Colon polyps
Pancreatic cancer Liver cancer Diabetes
Heart disease Other cancers
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