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Microsoft word - patient profile 9-17b

Patient Profile
Please submit this form to our Corporate office at: Raleigh Endoscopy Center 2417Atrium Dr Ste 101 Raleigh, NC
27607 or fax 919-791-2061

Name (print):________________________________ Date of Birth:___________ Procedure Date:____________
Emergency Contact:____________________________Relationship:_______________ Phone #:______________
Primary Care Physician:_________________________Reason for Procedure:_____________________________

Drug Allergies & Reaction:____________________________________ LATEX ALLERGY: Y / N
___________________________________________________________
PLEASE LIST ALL MEDICATIONS YOU TAKE, PRESCRIPTION AND NON-PRESCRIPTION
Medicine & Dose-Reason Taken Medicine & Dose-Reason Taken Medicine & Dose-Reason Taken
___________________________ _________________________ _________________________ ___________________________ _________________________ _________________________
___________________________ _________________________ _________________________
BLOOD THINNERS: Do You Take: Aspirin, BC powder, Aleve, Motrin, Ibuprofen, Vitamin E
Blood Thinners Such As: Coumadin Warfarin Plavix Levonox or Ticlid? Y / N
MEDICAL HISTORY
HEIGHT__________ WEIGHT____________
PLEASE CIRCLE IF YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING: CARDIAC: High Blood Pressure High Cholesterol Mitral Valve Prolapse Irregular Heart Rate Angina
Heart Disease (TYPE)____________________ Stent Pacemaker Heart Attack (MI) Congestive Heart Failure
PULMONARY: Asthma Emphysema COPD Sleep Apnea
GI: Acid Reflux Barrett’s Esophagus Colitis / Crohn’s Colon Polyps Colostomy Ulcers
Diverticulosis / Diverticulitis Colon Cancer
GU: BPH Urinary Incontinence
KIDNEY/ENDOCRINE: Diabetes Kidney Failure / Dialysis Thyroid Problems
NEUROLOGIC/MUSCULAR:Stroke Parkinson’s Migranes TIA’S Seizures: Date Of Last Seizure________
PSYCHOLOGIC: Depression Anxiety Mental Illness (type)_______________________________________
AUTOIMMUNE: Rheumatoid / Osteo Arthritis Lupus HIV/AIDS
MISC: Anemia Bleeding Disorder Cancer (type): ______ Radiation / Chemotherapy Date: _______________
Pregnant Y / N Breast Feeding Y / N
OTHER ILLNESSES NOT LISTED:________________________________________________________________
Do you have to take antibiotics before a medical or dental procedure? Y / N . FAMILY MEDICAL HISTORY
LIST FAMILY MEMBER THAT HAD THE FOLLOWING DISEASE (Immediate family only) Cancer: Esophageal_____________ Colon____________ Stomach______________OTHER___________________ Diabetes_______________ High Blood Pressure ______________ Heart / Lung Disease______________________ ENDOSCOPY/SURGICAL HISTORY
________________________________________ __________________________________________ ________________________________________ __________________________________________ ________________________________________ __________________________________________ Have you ever had any problems with anesthesia? Y / N __________________________________________

SOCIAL HISTORY
Do You Smoke? Y / N # Packs/day________ Smokeless Y / N (amount)_______________ Alcohol use: Never Occasionally Daily (# drinks/day)_________________ Rev 09-09

Source: http://raleighendoscopy.com/assets/uploaded/documents/90/Patient-Profile-9-17-09b.pdf