Paul E. Zachary Jr., MD

Paul E. Zachary Jr., MD

Mandi L. Barnes, FNP-C

1419 Westport Landing Place

Suite 103

Manhattan, KS 66502

P 785-539-8900

F 785-539-4425

www.manhattangastro.org

Please take a few minutes and fill out this questionnaire. Return completed form BEFORE/THE DAY OF your appointment on ______at______.

Name______Date of Birth______

Referring Physician______Primary Care Physician______

Main reason for this visit/procedure______

MEDICAL HISTORY

Have you had or been diagnosed with the following gastro-intestinal conditions? (Please circle all that apply)

Esophageal Reflux Duodenal Ulcer Ulcerative Colitis Jaundice Hepatitis A

Barrett’s Celiac Disease Crohn’s Disease Cirrhosis of Liver Hepatitis B

Esophageal Stricture Chronic Diarrhea Colon Polyps Gallstones Hepatitis C Esophageal Varices Chronic Constipation Colon Cancer Pancreatitis Gastritis Stomach Ulcer Diverticulosis Pancreatic Cancer Helicobacter Pylori Infection

Irritable Bowel Syndrome

Have you had or been diagnosed with any of the following other conditions? (Please circle all that apply)

Blood Transfusion Diabetes High Blood Pressure Asthma Heart Disease Thyroid Disease Emphysema Heart Murmur Artificial Heart Valve High Cholesterol

Any kind of Cancer: Type______

Please list any other medical problems you have or have had in the past

______

Have you ever had a test to screen for Colon Cancer? YES NO

If yes, please indicate which test and the year it was done in the space provided:

Barium Enema ______Flexible Sigmoid ______Colonoscopy______Stool Blood Test______

Please list all other surgeries and dates, if possible______

______

FAMILY HISTORY

Please circle any of the listed diseases that run in the family and indicate the relationship in the space provided

Colonic Polyps______Crohns Disease______Liver Disease______Colon Cancer______

Gallbladder Dis______Ulcerative Colitis______Pancreatitis______Other Disease______

CURRENT MEDICATIONS PHARMACY______

When listing your all of your medications, please include over-the-counter, vitamins, herbal supplements, etc.

Name / Dose / Name / Dose / Name / Dose

(CONTINUED ON BACK)

Please list any drug that you have had an ALLERGIC REACTION to, and the reaction

Name / Reaction

SOCIAL HISTORY (Please be sure to fill in EVERYTHING. Do not leave anything blank!)

Please list your occupation______

Please list your preferred language:______Race:______Ethnicity: Hispanic Non-Hispanic

Please circle your current marital status: Single Married Divorced Widowed

Please list the name and age of your spouse and children

Name / Age / Name / Age / Name / Age
Name / Age / Name / Age / Name / Age

Please Circle YES or NO and be sure to fill in answers for any secondary questions:

Do you smoke? YES NO If yes, how many packs a day______

Do you drink alcohol? YES NO If yes, how much per week______

Ever used IV drugs, marijuana, or cocaine? YES NO If yes, how long ago______

Ever had a body piercing? YES NO

Ever had a tattoo? YES NO

Ever had multiple sexual partners? YES NO

Ever had homosexual or bisexual partners? YES NO

Are you a vegetarian? YES NO

Do you use fiber supplements? YES NO If yes, what and how much______

Do you exercise regularly? YES NO If yes, what and how much______

How many glasses of water you drink a day?______How many cups caffeinated beverages a day?______

List any Hobbies you have______

How important is faith to you?______

Do you pray? YES NO

Do you have a religious preference? YES NO If yes, what affiliation______

REVIEW OF SYSTEMS (Please circle all that apply)

Gastrointestinal General Cardiovascular Neurologic/Psychiatric

Nausea/Vomiting Excessive Thirst Chest pain Stroke

Jaundice Chronic Fatigue Abnormal leg swelling Tremors

Vomiting Blood Weight Loss Irregular heart rate Numbness/Tingling

Frequent Heartburn Fever Atrial Fibrillation Seizures

Difficulty Swallowing Chills/Sweats Respiratory Dizziness

Food Sticking Swollen Lymph Nodes Pneumonia Panic Attack

Poor Appetite Bruise easy Asthma Depression

Excessive Gas/Bloating Bleed easy Exposure to TB Anxiety

Abdominal Pain Anemia Short of Breath Loss of Consciousness

Abdominal Cramping Ears Eyes Nose Throat Bronchitis Frequent Headaches

Greasy/Oily Stools Ear Infections Cough Genito/Urinary

Constipation Poor Vision Bones/Joints Last menstrual period______

Diarrhea Wear Eyeglasses Arthritis Abnormal Vaginal Bleeding

Leakage of stool Glaucoma Gout Leakage of Urine

Blood in Stool Cataracts Back Pain Urine Infections

Dark, Tarry Stools Nose Bleeds Osteoporosis Painful Urination

Skin Fever Blisters Pain/Stiffness in Neck Blood in Urine

Hives Hoarseness Muscle Weakness Kidney Stones

Rash Hearing Loss Frequent Urination

Allergic Reaction Difficulty with Erections

Enlarging Moles Difficulty Starting Stream