Peninsula Gastroenterology Medical Group, Gastroenterologists logo for print
Peninsula Gastroenterology Medical Group, Gastroenterologists
Redwood City: 2900 Whipple Ave | Suite 245 |Redwood City, CA 94062 • Phone: 650-365-3700
Mountain View: 2495 Hospital Drive | Suite 600 | Mountain View, CA 94040 • Phone: 650-964-3636

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Patient Medical History Form

Patient
Appointment Date:
Todays Date: December 8, 2023
First Name
Last Name
Date of Birth
Marital Status
Primary M.D.
Reason for Visit
Please check all that apply or "None" for each section below.
Past or Present Medical Illnesses
None Frequent Urinary Tract Infections Pancreatitis
Anemia Gallstones Paralysis
Asthma Heart Attack - MI Parkinson's Disease
Atrial Fibrillation Heart Murmur Pneumonia
Breast Cancer Hepatitis A Anesthesia Problems
Cancer Hepatitis B Reflux
Chronic Lung (COPD) Hepatitis C Rheumatic Fever
Cirrhosis of Liver High Blood Pressure Rheumatoid Arthritis
Colitis High Cholesterol Seizures
Colon Cancer High Triglycerides Skin Cancer
Colon Polyps HIV/AIDS TB Skin Test Positive
Congestive Heart Failure Irregular Heart Beat Sleep Apnea
Crohn's Disease Irritable Bowel Syndrome Stomach Ulcer
Depression Kidney Stone Stroke
Diabetes Kidney Disease Thyroid Disease
Diverticulitis Kidney Failure TB (Tuberculosis) 
Diverticulosis Lactose Intolerance Ulcerative Colitis
Duodenal Ulcer Migraines Uterine Cancer
Fatty Liver Osteoarthritis  
Other
Previous Surgeries / Hospitalizations / Procedures
None Heart Bypass Surgery Obesity Surgery
Appendix Heart Stent Pacemaker
Breast Heart Valve Replacement Prostate
C-Section Hemorrhoids Sigmoidoscopy
Cardiac Surgery Hiatal Hernia Stomach
Colon Resection - Left Hysterectomy Partial Thyroid
Colon Resction - Right Hysterectomy Total Tonsils
Colonoscopy Joint Surgery/Replacement Transplant Surgery
Defibrillator Kidney Tubal Ligation
EGD/Upper Endoscopy Liver Vasectomy
ERCP Liver Biopsy  
Gallbladder    
Other
Allergies
None Codeine Erythromycin IV Contrast Morphine Penicillin
Aspirin Demerol Iodine Latex Novocain Propofol 
Sulfa Versed Tape         
Other
Family History
Colitis Father Mother Child(ren) Brother(s) Sister(s) Grandparents
Colon Cancer Father
Age at Diagnosis
 Mother
Age at Diagnosis
 Child(ren)
Age at Diagnosis
 Brother(s)
Age at Diagnosis
 Sister(s)
Age at Diagnosis
 Grandparents
Age at Diagnosis
Colon Polyps Father Mother Child(ren) Brother(s) Sister(s) Grandparents
Crohn's Disease Father Mother Child(ren) Brother(s) Sister(s) Grandparents
Esophageal Cancer Father Mother Child(ren) Brother(s) Sister(s) Grandparents
Gall Bladder Disease Father Mother Child(ren) Brother(s) Sister(s) Grandparents
Heart Trouble Father Mother Child(ren) Brother(s) Sister(s) Grandparents
Liver Cancer Father Mother Child(ren) Brother(s) Sister(s) Grandparents
Liver Disease Father Mother Child(ren) Brother(s) Sister(s) Grandparents
Pancreatic Cancer Father Mother Child(ren) Brother(s) Sister(s) Grandparents
Stomach Cancer Father Mother Child(ren) Brother(s) Sister(s) Grandparents
Ulcer Disease Father Mother Child(ren) Brother(s) Sister(s) Grandparents
Ulcerative Colitis Father Mother Child(ren) Brother(s) Sister(s) Grandparents
Other
Social History Occupation
Patient Occupation Veteran
Social History - Alcohol
Never Rarely Daily I quit using alcohol
Weekly: # of drinks per week:
Social History - Caffeine
Never Rarely Daily I quit using caffeine
Weekly: # of drinks per week:
Social History - Tobacco
I use tobacco productsI quit using tobacco productsI have never used tobacco products
Cigarettes:
1 pack per day 1 1/2 pack per day 2 packs per day Greater than 2 packs per day
Cigars Smokeless tobacco     
Social History Illicit Drug Use
I use illicit drugs I quit using illicit drugs
I have never used illicit drugs Injection drug use
Review of Symptoms
Constitutional
None Loss of appetite
Chills Night Sweats
Fever 
Other
Gastrointestinal
None Diarrhea Rectal urgency
Abdominal Pain Difficulty swallowing Reflux
Anal/rectal Pain Flatulence/gas Soiling stool/incontinence
Belching Heartburn Vomiting
Black stools Mucus in Stool Weight Gain
Bloating Nausea Weight Loss
Change in Bowel Habits Pain with Bowel Movement    
Consitpation Rectal bleeding    
Other
Cardiovascular
None Heart murmur as an adult Shortness of breath
Chest pain with exertion/angina Shortness of Breath with exertion    
Palpitations
Other
Respiratory
NoneSnoring
Cough up bloodShortness of breath
Other
Skin
None Skin Rash Itching
Jaundice Suspicious Lesions
Other
Musculoskeletal
NoneMuscle pain
Back Pain 
Other
Ears, Nose and Throat
NoneNose Bleeds
Ears ringingSore Throat
Hoarseness 
Other
Hematologic
NoneProlonged bleeding
Easy Bruising
Other
Psychiatric
NoneDepression
Anxiety/panic 
Other
Neurological
None Numbness in extremities Memory Disturbance
Dizziness Seizures Fainting Spells
Stroke/Weakness Frequent Headaches Tremors
Other
Urinary
None Blood in Urine Change in urinary frequency
Pain with Urination Kidney stones    
Other
Endocrine
NoneHeat Intolerance
Hair Change / Loss 
Other
Eyes
NoneWear glasses/contacts
Blurred visionLoss of vision
Other
Immunologic
NoneStrong allergic reactions
Allergies (environmental)Persistent Infections
Other

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Atherton Endoscopy Center


Map & Directions

While you are a patient at Atherton Endoscopy Center, our highly competent and professional staff will care for you. Everyone from the receptionist to the physician embraces our philosophy of patient-focused care. Above all, our staff is friendly and concerned for your comfort.