Columbia Office (near Costco): 8186 Lark Brown Road Suite 104 Elkridge, MD 21075 The Crain Mayo Medical Building: 1720 S Crain Highway Suite 102 Glen Burnie, MD 21061 The private practice of Mukul Khandelwal, MD & Mahmood Solaiman, MD, FACG Phone: (410) 590-8920 Fax: (410) 553-2345 www.MDgastro.net The following information is very important to your health. Please take time to fully and completely fill out this important information. NAME: ______________________________ TODAY'S DATE: _________________ DATE OF BIRTH: __________________ REFERRED BY________________________ REASON FOR VISIT______________________________________________________ Past or Present Medical Problems: O None O Colon Cancer O Diverticulitis O Diverticulosis OAnemia O Crohn’s Dis. O Ulcerative Col. O Irritable Bowel O Celiac Sprue O Pancreatitis O Barrett’s Esop. O GERD O Esop. Cancer O Ulcer O Gallstones O Hepatitis O Liver Disease O Stroke O Osteoporosis O Lupus O Arthritis O Diabetes O Heart Disease O Atrial Fib. O Irreg. heartbeat O Hypertension O Glaucoma O Gout O High Cholesterol O Sleep Apnea O Breast Cancer O Lung Cancer O Asthma O Emphysema/COPD O Anxiety O Prostate Cancer O Kidney Disease O Kidney Stones O Psychiatric Dis. O Depression O Seizure Disorder O Gyn Cancer O Bleeding Disorder Other__________________________________________________________ Surgeries/Hospitalization/Procedures: O None O Colon Surgery O Gallbladder Surgery O Prostate Surgery O Colonoscopy O EGD/endoscopy O Colostomy O Hysterectomy O C-Section O Joint Surgery O Heart Surgery O Heart Stent O Pacemaker O Appendectomy O Blood Transfusions Other_______________________________________________ O Hernia Surgery O ERCP O Hiatal Hernia Repair O Defibrillator (AICD) O Gastric BypassSurgery O Orthopedic Surgery Social History - Marital Status Recreational Drugs O None Children ONone How many_____ O I have used IV drugs in the past. O Single O Separated O Married O I currently use recreational drugs. O Divorced O Widowed O Partnered O I have been treated for substance abuse Social History -Alcohol Social History - Tobacco O Never O More than 2 days/week. O I use tobacco products. O Rarely O Less than 2 days/week. O I have never used tobacco products. O Daily O I quit using alcohol O I quit using tobacco products. Social History - Occupation _________________________ O Retired Review of Systems Gastrointestinal O None O Blood in Stool O Heartburn O Loss of Appetite O Abdominal pain O Change in Bowel Habits O Hemorrhoids O Milk Intolerance O Belching O Constipation O Incontinence O Nausea O Black Stools O Diarrhea O IBS O Bloating O Gas O Jaundice O Vomiting O Painful Bowel Movement O Other________________ Genitourinary Skin/Integument O None O Irregular Menstruation O None O Rash O Blood in Urine O Pain on Urination O Itching O Other__________________ O Dark Urine O Sexually Transmitted Disease O Diminished Urine Flow O Urinary Incontinence O Frequent Urinary Infections O Other___________________ O Frequent Urination Columbia Office (near Costco): 8186 Lark Brown Road Suite 104 Elkridge, MD 21075 The Crain Mayo Medical Building: 1720 S Crain Highway Suite 102 Glen Burnie, MD 21061 The private practice of Mukul Khandelwal, MD & Mahmood Solaiman, MD, FACG Phone: (410) 590-8920 Fax: (410) 553-2345 www.MDgastro.net Cardiovascular O Angina/Chest Pain O Irregular Heart Beat O Ankle Swelling O Other_____________________ Neurological Endocrine O None O Seizures O None O Excessive Thirst O Dizziness O Stroke or Paralysis O Cold Intolerance O Headaches O Other __________________ Constitutional Psychiatric O None O Weight Gain O None O Depression O Fever O Weight Loss O Abnormal Sleep O Memory Loss/Confusion O Night Sweats O Other _________________ O Chronic Anxiety Eyes Hematologic O None O Eye Pain O None OProlonged Bleeding O Change in Vision O Other__________________ O Enlarged Glands O Dry Eyes Ears, Nose and Throat Musculoskeletal O None O Hoarseness O None O Muscle Pain O Bleeding Gums O Mouth Sores O Back Pain O Chronic Sore Throat O Nose Bleeds O Joint Pain O Dry Mouth O Other __________________ Respiratory Immunologic O None O Wheezing O None O Pneumonia O Chronic Cough O Other ______________ O Ear Infections O Other ____ O Shortness of Breath O Flu FAMILY HISTORY Colon Cancer Colon Polyps Crohn’s Disease Ulcerative Colitis Esophageal Cancer O Gastric Cancer Pancreatic Cancer Liver Disease Gyn Cancer Breast Cancer Allergies: O None O Aspirin Father O O O O O O O O O O O Demerol/Fentanyl O Eggs Mother O O O O O O O O O O Child(ren) O O O O O O O O O Brother/Sister Other O O O O O O O O O O O O IV Contrast or Iodine O Propofol/Diprivan O Penicillin OVersed List of Medications: Please list on the left margin. The above is true and correct to the best of my belief. Patient's Signature:__________________________________________________ Date:___________________ O O O O O O O O O O Sulfa O Latex O Other________