Digestive Health Associates of Texas, P.A.
PATIENT UPDATE INFORMATION (Dr. Luk – 4/2017)
Name ______Date of Birth ______Today’s Date______
Reason for Visit/Procedure ______
Primary Physician (and Referring Physician if different) ______
(Circle appropriate answer – including YES or NO - for ALL questions and list details in the blanks or on separate page)
General health is Excellent / Very good / Good / Fair / Poor LAST COLONOSCOPY DATE (or None) ______
Height ______Weight ______Number of drinks per week ______Number of cigarettes per day ______
LIST ALL KNOWN ALLERGIES, OR STATE NONE:
LIST ALL MEDICATIONS, PRESCRIPTION AND NON-PRESCRIPTION, OR STATE NONE:
SINCE YOUR LAST VISIT, HAVE YOU HAD ANY OF THE FOLLOWING ? Detail any Yes answers.
Hospitalizations Yes/No Surgeries Yes/No Emergency Room visits Yes/No Prolonged illness Yes/No
Frequency of BM’s: 2-3 a day / 1 a day / 1 every 2 – 3 days / 1 every week / less than 1 a week
Use laxatives at least 1 a week Yes/No Use fiber supplements Yes/No Which one?
DO YOU HAVE ANY OF THE FOLLOWING? (Circle condition and describe) or Circle NONE
Pacemaker / Defribrillator Depression / Psychiatric diseases
Nerve stimulator / Pain pump Stroke / Seizure / Weakness / Numbness
Heart stents / bypass / artificial valves Fibromyalgia / Rheumatic diseases
Heart disease / Heart condition / Palpitations Cancers / Transplants / Implants
High blood pressure AIDS or HIV
Congestive heart failure / Swelling of feet or ankles Immune diseases / MRSA / Frequent infections
Emphysema / Asthma / Shortness of breath Diabetes / Thyroid diseases
Sleep apnea / CPAP / Loud snoring Kidney disease / Urination problems / Prostate problems
Reflux / Heartburn / GERD Joint Replacement / Arthritis
Hepatitis / Liver diseases Glaucoms / Blurred vision / Eye pain
Easy bleeding / Easy bruising Rectal bleeding / Blood in stools
Nausea / Difficulty with sedation /anesthesia Family history colon cancer / colon polyp
Patient signature______Date ______