ANUBHA SINHA, M.D. Hunterdon Digestive Health Specialist
Location 1: 170 Route 31 Flemington, NJ 08822
Patient Health Questionnaire Please fill out as much as possible to help with your medical care. Use the back of the sheet if you run out space. For medications, please include the dosage. Date: ___________ Patient Name: ________________________________________ Date of Birth: _____/_____/_____ Marital Status: _________ Primary Doctor: _____________________________________________ Referring provider: ___________________________________________ **REASON FOR VISIT: ** _______________________________________ Past/Present Gastrointestinal Illnesses (Please circle) Anemia Diverticulitis Hepatitis B Diverticulosis Hepatitis C Duodenal Ulcer Irritable Bowel Syndrome Cirrhosis of the Liver Fatty Liver Lactose Intolerance Gallstones Pancreatitis Colon Cancer Gastric Cancer Colon Polyps Gastric Polyp Stomach Ulcer Chron’s Disease H. Pylori Ulcerative Colitis Depression Hepatitis A Do you Smoke? Yes / No **If yes, how many packs per week? __________ Do you Drink Caffeine? Yes / No **If yes, how many drinks per week? ________ Do you Drink Alcohol? Yes / No **If yes, how many drinks per week? ________ Past Surgeries (Examples: Heart bypass, appendectomy etc) Medication Allergies OR LATEX(please state drug and the reaction) Medications (please include all medications including over the counter medicines. Include dosing information) Medication frequency *Are you on blood thinners? IE Coumidin, Lovenox, Aspirin, Plavix, or Other.
Do you have a history of endocarditis or artificial heart valve? Yes / No
Do you have a pacemaker? Yes / No If yes, Cardiologist
Do you have a history of kidney problems? Yes / No Do you have any other serious medical problems for which you currently being treated? Yes / No Family History (any stomach, colon, liver disease or cancer) Please Circle Colitis Heart Trouble Colon Cancer Liver Cancer Colon Polyps Liver Disease Chron’s Disease Pancreatic Cancer Esophageal Cancer Stomach Cancer Gall Bladder Disease Ulcer Disease OTHER__________ Review of Systems: Please circle any symptoms that you currently have or have suffered from in the past. General Weight loss Gastrointestinal: Heartburn Cardiovascular: Chest pain Pulmonary: Chronic cough Skin: Rash Musculoskeletal: Joint pains/swelling Stiff joints Back pain Sciatica Ears, Nose and Throat: Hearing loss
Anchor of the Soul Mission Outreach Health and Safety Suggestions Always stay in groups. Never go off on your own. Keep cameras with you or leave in approved areas. Please remember, safety first, no matter what we are trying to accomplish. NEVER accept a package from anyone that you are not 100% sure what is inside. Feel free to express ANY concerns to your team leader. Keep passport wh