Greg S. Cohen, MD

Northwestern University FeinbergSchool of Medicine Department of Medicine – Division of Gastroenterology

201 E Huron St, Galter 11-205

Chicago, IL60611 (312) 695 – 4452

The following information will become part of your confidential medical record

Date/Time of First Appointment _____/______/_____ at ______m.

Name:______Birthdate: _____/______/____

LAST FIRST MIDDLE INITIAL

HISTORY OF ILLNESS

(Please describe the problems you are having):

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PAST MEDICAL HISTORY

(Please list all medical problems, past surgeries, and hospitalizations including dates and hospital names):

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CURRENT MEDICATIONS:

Name of Medication Dosage Start Date Prescribed by

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ALLERGIES:

Name of MedicationReaction

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SOCIAL HISTORY

Sex :  Male  Female Education level:______Ethnicity:______

Marital Status:  Single Married  Widowed Divorced (Children if yes, how many _____ )

InterestHobbies:______

Alcohol use:  Never Former when did you stop?  Occasional  Daily

Tobacco use:  NeverFormer when did you stop?  Current

Cigarettes:______Cigars:______Chewing Tobacco:______

Illicit drugs: (explain)

FAMILY HISTORY

Is there any family history of colon cancer? Circle One Y N

Is there any family history of liver disease? Circle One Y N

List below any cases of cancer, peptic ulcer, Crohn’s disease, ulcerative colitis, gall bladder disease, liver, hereditary conditions, or other significant conditions: (e.g., heart disease, hypertension, diabetes, etc.)

If deceased, cause of death Age

Parents______

Brothers/Sisters______

Grandparents______

OCCUPATIONAL HISTORY

Current Employment______Past Employment______

REVIEW OF SYSTEMS AND SYMPTOMS

Please  the following symptom/disease you’ve recently had or now have.

ConstitutionalNoseLungs/Respiratory

Recent Weight Loss/Amount ____Frequent dischargeShortness of breath

Recent Weight Gain/Amount ____Nose bleedsAsthma

Fever Other______Wheezing/Cough

FatigueMouthAbnormal Chest x-ray

WeaknessUlcers/soresNight Sweats

Change in appetiteLoss of tasteTuberculosis

Special Diet for Medical ConditionFull/partial denturesOther______

Other______Other______Genitourinary

EarsEyesUrinary tract infection

Hearing lossBlurred or double visionBlood in urine

Hearing aidLoss of sightBurning with urination

Ear painGlassesDifficult urination

Ear ringingPainKidney stones

Other______Other______Sexual difficulties

ThroatAllergic/ImmunologicProstate trouble

Frequent sore throatAllergies/not medicationOther______

Difficulty swallowingAbnormal immune systemPsychiatric

HoarsenessHIV / AIDS Depression

Other______Other______ Past evaluation/treatment

 Other______

MusculoskeletalAbdominal/GastrointestinalEndocrine

Arthritis Diarrhea Diabetes  Joint swelling Vomiting blood  Thyroid disease

Lupus, scleroderma or relatedVomiting Post-menopausal

Joint painConstipation Other______

Back painCrohn’s diseaseCardiovascular

Muscle weakness/painUlcerative colitisChest pain

Other ______Inguinal hernia Mitral valve prolapse

SkinEsophageal reflux Ankle/leg swelling

Dermatitis/rash/hivesIrritable bowel syndrome Pacemaker

Jaundice/yellow skinUlcers History of heart attack

History of MammogramAbdominal Pain Irregular heart beat

Breast cancerIndigestion Palpitations

ItchingNausea High blood pressure

PsoriasisBloating Other ______

Nodules/bumpsDifficulty swallowing foodNeurological

Bruise easilyGallstones Memory loss/Confusion

Other______Rectal Bleeding Seizure disorder

Hematologic/LymphaticHepatitis/liver disease Tremors

Swollen glandsHemorrhoids Dizziness

Blood diseaseBelching – gas Headaches

AnemiaColitis Fainting

Abnormal blood count Inflammatory bowel disease Other______

Bruise easilyHeartburn

Blood transfusion when?______ Fecal incontinence/stool leakage

Other______Other ______

Date of last eye exam?______

Menstrual:

Age when periods began:______regular? ______

Date of last period______

Date of last pap smear______

Bleeding after menopause?______

Are outside medical records available?

Circle oneYN

Patient’s Signature:______Date: ______

Physician Signature: ______Date: ______