Last Name:*
First Name:*
SSN (Social Security Number):*
Gender:* Man Woman
Address:*
PHONE No:
Mobile (Phone) No:*
Home (Phone) No:
Email*
Profession
Name of Employer
How did you find out about the doctor?*
EMERGENCY CONTACT INFORMATION:
Full Name
Family Relationship
Phone No.
WEIGHT HISTORY
Weight (in kg)*
Height (in cm)*
BODY MASS INDEX (BMI)
CURRENT ILLNESS
Symptoms:
Time of Onset of Symptoms:
Are you taking any medication?
Have you done any relevant medical tests?
ASSESSMENT OF QUALITY OF LIFE WITH GASTROESOPHAGEAL REFLUX DISEASE (GERD)
Are you taking any medications at this time? Yes No
If not, how long have you been stopped taking medications?
Score:
Choose the one that best describes your quality of life in the last 2 weeks.
Total Score
PAST MEDICAL HISTORY (PMH)
PEDIATRIC MEDICAL HISTORY
Have you gone through the typical (common) childhood illnesses?
Have you suffered from any other serious or unusual illnesses such as hepatitis, rheumatic fever, Type 1 diabetes, kidney diseases, cancer, etc. during childhood?
Have you ever experienced excessive bleeding after an injury or tooth extraction? Yes No
Have you ever needed a blood transfusion? Yes No
ADULT PATIENT MEDICAL HISTORY
Please, note below any diseases that you suffer from, are being treated for or you have been hospitalized in the past.
Other diseases (please, describe here in detail)
FOR WOMEN
Did you have normal (vaginal) births or C-sections?
How many pregnancies have you had in total?
Do you have a history of recurrent miscarriages, and if so, has it been investigated?
Did you have any complications during pregnancy?
How long ago was your last normal menstrual period?
FOR MEN
Do you have problems with your prostate?
Do you have trouble urinating (such as difficulty initiating urination, urinary dribbling, feeling of incomplete bladder emptying, etc)?
How many times do you get up at night to urinate?
PAST SURGICAL HISTORY
* Ναι Όχι
Describe the type of surgery, date, hospital and outcome – complications
1.
2.
3.
4.
MEDICATIONS
* Yes No
Please, note all medications that you are currently using and their dosages. Do not neglect to mention the medications that are not taken daily but only when symptoms are present.
1.
2.
3.
4.
5.
6.
7.
8.
Are you taking any medications to reduce the blood clot? Yes No
ALLERGIES
* Yes No
1.
2.
3.
4.
FAMILY HISTORY
Is your father alive? Yes No
Serious diseases
Mother:
Is your mother alive? Yes No
Serious diseases
Brothers and Sisters:
Are your brothers and sisters alive? Yes No
Serious diseases
SOCIAL HISTORY
Do you smoke? Yes No
Did you smoke in the past? Yes No
When did you stop smoking?
How many packs of cigarettes did you smoke a day?
How many years did you smoke in total?
Do you drink alcohol? Ναι Όχι
Which is your favorite drink?
How often do you drink?
How many glasses do you drink at a time?
What kind of job have you done for most of your life?
Have you worked in an environment with exposure to risk factors such as chemicals, asbestos, smoke, etc.?
GASTROINTESTINAL
Have you lost weight recently without dieting or changing your dietary habits? Yes No
Do you have pain or difficulty swallowing? Yes No
Do you have loss of appetite or an aversion to certain foods? Yes No
Have you noticed any changes in your bowel habits? Yes No
Have you noticed black stools or blood in your stools? Yes No
Do you have chest pain, heartburn or other reflux symptoms? Yes No
CARDIOVASCULAR
Do you have chest pain when you get tired or walk up stairs? Yes No
Do you sleep with pillows under your neck due to shortness of breath (dyspnea)? Yes No
Do you wake up at night with shortness of breath (dyspnea)? Yes No
RESPIRATORY
Do you have difficulty breathing when you get tired or you walk up stairs? Yes No
Can you walk up 2 flights of stairs without having shortness of breath (dyspnea) or pain? Yes No
Have you noticed any changes in your voice? Yes No
Do you have a chronic cough or phlegm? Yes No
Have you ever coughed up blood? Yes No
URINARY
Do you have felt a burning or stinging sensation or do you have pain or blood when you urinate? Yes No
Do you have a history of Urinary Tract Infections (UTIs)? Yes No
Have you had renal colic? Yes No
Do you have a history of pyelonephritis or other kidney (renal) disease? Yes No
NEUROLOGIC
Have you ever had epilepsy or seizures? Yes No
Have you ever had severe headaches? Yes No
Have you ever had a sudden loss of vision or hearing? Yes No
Have you ever had a loss of movement or feeing (numbness) in your limbs? Yes No
MENTAL HEALTH
Have you ever had depression, anxiety, or other emotions that had an impact on your health? Yes No
Have you ever been under the supervision of a psychologist? Yes No
Are you taking any medication for depression? Yes No
Have you ever had problems with alcohol or other drug use? Yes No
Have you used marijuana, cocaine, or other substances in the last year? Yes No
OTHER HISTORY DETAILS & COMMENS
If there is anything else you would like to add or mention, please fill in below
