Medical History Questionnaire Upper Gastrointestinal Surgery

Medical History Questionnaire

Esophagus - Stomach Conditions

Upper Gastrointestinal Surgery requires an individualized approach, investigation and treatment. To achieve this, we need to know as much information as possible about your general medical history and the problems you are facing.
It is important that you complete the questionnaire as fully and as accurately as possible.

Last name

First name

AMKA (Greek Social Security Number)

Place of residence

How did you hear about the doctor?

Contact Details

Mobile

Landline

Occupation

Employer

Emergency Contact Details

Last name

First name

Relationship

Phone

Weight History

Weight (in kg)

Height (in cm)

Body Mass Index

Present Illness

Symptoms

Symptom onset time

Medication for the symptoms?

Relevant tests?

For Gastroesophageal Reflux

Are you currently taking medication for reflux?

If not, how long ago did you stop?

Specialized Gastroesophageal Reflux Questionnaire

Select the option that best describes your quality of life over the last 2 weeks
Score:
0 = No symptoms
1 = Symptoms but not bothersome
2 = Bothersome symptoms but not daily
3 = Bothersome symptoms daily
4 = Symptoms that affect daily activities
5 = Symptoms that prevent daily activities

16. How satisfied are you with your current condition?

Satisfied Neutral Dissatisfied

Total score

Specialized Laryngopharyngeal Reflux Questionnaire

Total score

Pediatric History

Have you had the typical childhood illnesses?

Yes No

Other serious or unusual conditions during childhood? (e.g. hepatitis, rheumatic fever, type 1 diabetes, kidney disease, neoplasms etc.)

Yes No

Have you ever had excessive bleeding after an injury or tooth extraction?

Yes No

Have you ever needed a blood transfusion?

Yes No

Adult Life History

Other conditions (describe in detail)

History for Women

Vaginal deliveries and cesarean sections?

How many pregnancies have you had in total?

Do you have a history of miscarriages, and if so, has this been investigated?

Did you have complications during pregnancy?

Yes No

How long ago was your last normal period?

History for Men

Do you have known prostate problems?

Yes No

Do you have difficulty urinating? (difficulty starting, dribbling, feeling of incomplete emptying etc.)

Yes No

How many times do you get up at night to urinate?

Surgeries

Previous Surgeries

Yes No

Describe the type of procedure, date, hospital and outcome/complications

Medications

Do you take medication?

Yes No

List medications, with dosage. Do not forget medications that are not taken daily but only when symptoms occur

Are you taking blood-thinning medication?

Yes No

Allergies

Do you have any allergies?

Yes No

Please note any known allergies

Family History

Significant hereditary conditions in the family? (Diabetes, heart disease, obesity, malignancies etc.)

Is your father alive?

Yes No

Serious conditions of father

Is your mother alive?

Yes No

Serious conditions of mother

Are your siblings alive?

Yes No

Serious conditions of siblings

Social History

Do you smoke?

Yes No

Did you smoke in the past?

Yes No

Year you stopped?

How many packs per day?

For how many years in total?

Do you drink alcohol?

Yes No

Preferred drink?

How often?

How many glasses each time?

What occupation have you held for most of your life?

Have you worked in an environment with exposure to risk factors? (chemicals, asbestos, smoke etc.)

Yes No

Gastrointestinal

Have you recently lost weight without trying (without dieting or changing your diet)?

Yes No

Do you have pain or difficulty swallowing?

Yes No

Do you have reduced appetite, or aversion to specific foods?

Yes No

Have you had 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

Do you have a family history of gastrointestinal cancer?

Yes No

Do you have a family history of gynecologic cancers?

Yes No

Cardiovascular

Do you have chest pain when you get tired or climb stairs?

Yes No

Do you sleep with extra pillows because of shortness of breath?

Yes No

Do you wake up at night short of breath?

Yes No

Respiratory

Do you have difficulty breathing when you get tired or climb stairs?

Yes No

Can you climb 2 flights of stairs without shortness of breath or pain?

Yes No

Have you noticed changes in your voice?

Yes No

Do you have a chronic cough/phlegm?

Yes No

Have you ever coughed up blood?

Yes No

Urinary

Do you have pain, burning or blood when urinating?

Yes No

History of frequent urinary tract infections?

Yes No

Have you had renal colic (kidney stone pain)?

Yes No

Do you have a history of pyelonephritis or other kidney disease?

Yes No

Neurological

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 loss of movement or sensation in your limbs?

Yes No

Mental Health

Have you ever had problems with depression, anxiety, or other feelings that have affected your health?

Yes No

Have you ever been under the care of a psychologist?

Yes No

Are you taking any medication for depression?

Yes No

Have you ever had problems with alcohol or use of other drugs?

Yes No

Have you used marijuana, cocaine or other substances in the last year?

Yes No

Other History & Comments

If there is anything else you would like to add or mention, please fill in below

Appointment

How would you like the doctor to contact you to evaluate your answers based on the medical history you completed: *

In-office appointment Video call appointment

If you wish to schedule an appointment to evaluate and assess your medical history with Dr. Kourkoulos at the clinic, please select below the time slot that usually suits you for scheduling your appointment:

11.00 am – 2.00 pm 2.00 pm – 5.00 pm 5.00 pm – 8.00 pm

If you select a time slot, our secretary will contact you to confirm the day and time

I hereby declare that the above information is accurate and true and I consent to Dr. M. Kourkoulos processing the above information concerning me solely for the purpose of evaluating my condition and the possibility of treating it with the most appropriate procedure based on the above indications, and, upon completion of the above evaluation, to contact me at the telephone number provided in order to give me information based on my answers and to schedule/confirm an appointment. Finally, I understand and consent to the above information concerning me being retained, solely for the aforementioned purpose and for a period of two (2) months.