GI First Visit Questionnaire Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
*
-
Month
-
Day
Year
Date
Date of your appointment with Dr. Fuchs
-
Month
-
Day
Year
Date
Briefly describe the chief complaint that prompted this visit:
Did you see any other doctor for this issue?
Yes
No
Please list the doctors seen for this issue
Have you had any tests for this issue?
Yes
No
Please list the test performed for this issue
Do you/have you taken any medications for this issue?
Yes
No
Personal Medical History - Check all that apply:
Abnormal liver tests
High blood pressure
AIDS/HIV
Liver disease/hepatitis
Anemia
Asthma
Blood disorders
Pneumonia
Kidney disease
Diverticulosis
Cancer
Tuberculosis
Diabetes
Thyroid problems
Gallbladder problems
Ulcer Diseases
Heart Disease
Seizures/Stroke
Heart murmur
Psychiatric
Chron’s
Stomach Ulcers
Colitis
Reflex diseases
Other
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Surgical History
List any surgeries you have had and the year they were performed:
Recent Hospitalizations
Yes
No
List Hospital
Please list your current medications
Have you ever had a colonoscopy or endoscopy in the past?
Yes
No
Approximate date of colonoscopy/endoscopy
-
Month
-
Day
Year
Date
Which doctor performed your colonoscopy/endoscopy?
Social History
Rows
Yes
No
Alcohol
Smoker
Family History - Check all that apply and specify relationship:
Rows
Check if applicable
Relationship?
Add Comments
Colon Cancer
Father
Mother
Sister
Brother
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Pancreatic Cancer
Father
Mother
Sister
Brother
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Stomach Cancer
Father
Mother
Sister
Brother
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Prostate Cancer
Father
Mother
Sister
Brother
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Esophageal Cancer
Father
Mother
Sister
Brother
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Breast Cancer
Father
Mother
Sister
Brother
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Colon Polyps
Father
Mother
Sister
Brother
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Liver Disease
Father
Mother
Sister
Brother
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Chron’s Disease
Father
Mother
Sister
Brother
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Ulcerative Colitis
Father
Mother
Sister
Brother
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
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Review of Systems - Please check any persistent or recurring symptoms:
Gastrointestinal
General
ENT
Respiratory
Cardiovascular
Skin
Neurologic
Hematologic
Psych
Genitourinary
Musculoskeletal
Submit
Should be Empty: