DEAN C. KRAMER, M.D.
1155 N.W. 64TH TERRACE
GAINESVILLE, FLORIDA 32605
TELEPHONE (352) 331-6736
Dear Patient:
The following questions are designed to obtain some general information about your
health history. By answering these general questions, it is intended that more time will
be available for detailed discussion of your major gastrointestinal problems. Please
complete the FRONT and BACK of ALL pages.
Your appointment is scheduled for ______________________at__________a.m./p.m.
Please complete this form and bring it with you at the time of your appointment.
PLEASE PLAN TO ARRIVE AT LEAST 15 MINUTES BEFORE THE ABOVE
SCHEDULED TIME so that you may register and have your office records prepared.
Please bring ALL of your prescription medications with you.
FINANCIAL INFORMATION: My office will only file an insurance claim with your
primary insurance carrier ( for example, Medicare, Blue Shield, etc.) We cannot be
responsible for filing claims with secondary insurers. The patient will be held
responsible for payment of any deductibles and/or copayments. Please be prepared to
pay your portion of your charges by cash or check at the time the service is provided.
My staff will be happy to provide you with information about how to file your claim for
any secondary insurance benefits.
PATIENT INFORMATION (Please print or type)
Name:__________________________________________Sex: Male [ ] Female [ ]
Address: ________________________________________Age:__________________
Social Security Number:_________________Home Phone:______________________
Driver’s License Number:________________Office Phone:______________________
Present Employer:______________________________________________________
Employer’s Address:____________________________________________________
Years Employed by Present Employer:_____Position or Title:____________________
Spouse’s Name:_______________________Spouse’s Age:_____________________
Spouse’s Employer:_____________________________________________________
Spouse’s Employer’s Address:____________________________________________
Spouse’s Employer’s Phone:______________________Spouse’s Title:____________
Nearest Friend or Relative NOT living with you:_______________________________
Address:______________________________________Telephone:_______________
Relationship:__________________________________________________________
PAGE 2
Marital Status: [ ] single [ ] married [ ] widowed [ ] separated [ ] divorced
Person responsible for payment of your professional fees: [ ] myself
Other:________________________________________________________________
(indicate name, address, and telephone number:______________________________
Referred by:___________________________________________________________
List the names of all the doctors you have seen in the last two years and the reason
why you have seen the doctor(s):__________________________________________
INSURANCE INFORMATION
Do you have hospitalization insurance? (check one) [ ] YES. . . . . [ ] NO
Is your illness covered by Workers’ Compensation insurance? [ ] YES. . . . .[ ] NO
If you have insurance coverage, please indicate the type(s):
[ ] Medicare [ ] Medicare Number:_____________________________________
[ ] Blue Cross/Blue Shield [ ] Contract Number_____________________________
[ ] Other Insurance Coverage (List below)___________________________________
_____________________________________________________________________
Name and address of insurance companies and contract numbers:________________
PLEASE STATE YOUR REASON FOR SEEING DR. KRAMER
Please describe your reason here:_________________________________________
_____________________________________________________________________
PAST MEDICAL HISTORY
Serious past injuries: (describe the type of injury and approximate date of
occurrence)___________________________________________________________
Previous surgery: (place a mark in the box next to the type of surgery you have had
and indicate the approximate date of the surgery)
[ ] Appendix_____________________ [ ] Hernia________________________
[ ] Cataracts_____________________ [ ] Hysterectomy__________________
[ ] Gallbladder___________________ [ ] Stomach ulcer surgery___________
[ ] Hemorrhoid surgery____________ [ ] Tonsils _______________________
[ ] Heart surgery _________________ [ ] Colon surgery_________________
Other surgery:_________________________________________________________
PAGE 3
Place a mark in the box next to illness or illnesses that you currently have or have had
in the past:
[ ] Anemia [ ] Gout [ ] Mental illness
[ ] Arthritis [ ] Heart attack [ ] Nervous stomach
[ ] Asthma [ ] Heart trouble [ ] Osteoporosis
[ ] Cancer [ ] Hepatitis [ ] Spastic colon
[ ] Cirrhosis of the liver [ ] High blood pressure [ ] Stomach ulcers
[ ] Emphysema [ ] Kidney Infections [ ] Sugar diabetes
[ ] Gallstones [ ] Kidney stones [ ] Thyroid trouble
[ ] Glaucoma [ ] Liver disease [ ] Yellow jaundice
FAMILY HISTORY
Is your mother living? [ ] Yes [ ] No (cause of death)_______________________
Is your father living? [ ] Yes [ ] No (cause of death)_______________________
Have any family members ever had any of the following diseases? If yes, place a
check mark in the box next to the illness. In the space next to the illness put the code
letter of the family member who had the illness—Use [M] for mother, [F] for father, [S]
for sister, [B] for brother, [C] for child, [GP] for grandparent, [A] for aunt, [U] for uncle,
[CS] for cousin.
[ ] Colon Cancer ______________________________________________________
[ ] Colon Polyps _______________________________________________________
[ ] Ulcerative colitis_____________________________________________________
[ ] Crohn’s Disease_____________________________________________________
[ ] Diabetes___________________________________________________________
[ ] Breast Cancer______________________________________________________
[ ] Ulcer disease_______________________________________________________
[ ] Liver disease_______________________________________________________
[ ] Uterine cancer______________________________________________________
SOCIAL HISTORY AND HABITS
Place a mark in the box that most closely approximates how much of the following
alcoholic beverage you drink in the course of an average week:
Beer: [ ] none [ ] one to six cans
[ ] 7-18 cans [ ] more than 18 cans
Wine: [ ] none [ ] less than 16 ounces
[ ] between 16 and 32 ounces [ ] more than 32 ounces
Liquor: [ ] none [ ] less than 16 ounces
[ ] between 16 and 32 ounces [ ] more than 32 ounces
PAGE 4
Place a mark in the box that most closely approximates how many cigarettes you
average smoking each day:
[ ] none [ ] less than ½ pack [ ] less than one pack
[ ] one to two packs [ ] two to three packs [ ] more than three
Place a mark in the box that most closely approximates how many years that you have
been a cigarette smoker”
[ ] 1-8 years [ ] 9-15 years [ ] 16-25 years [ ] more than 25 years
Place a mark in the box that most closely approximates how much of the following
beverages you drink each day:
Coffee: [ ] none [ ] 1-3 cups [ ] 4-10 cups [ ] more than 10
Tea: [ ] none [ ] 1-3 cups [ ] 4-10 cups [ ] more than 10
Colas: [ ] none [ ] 1-3 bottles [ ] 4-10 bottles [ ] more than 10
Place a circle around the number of years that you attended school:
None 1 2 3 4 5 6 7 8 High School 9 10 11 12 College 1 2 3 4
Place mark in the box next to any postgraduate degrees you received:
[ ] Masters [ ] PhD. [ ] M.D. [ ] DDS [ ] J.D.
[ ] Other:___________________________________________________________
Please describe your job or occupation (examples: student, lawyer, homemaker, real
estate agent, banker, nurse, etc.)__________________________________________
List below all the medications that you have taken regularly in the last 4 weeks
(including aspirin products, arthritis medications, vitamins, birth control pills, etc.).
Please bring all of your medications with you.
NAME OF THE DRUG DRUG HOW OFTEN YOU TAKE LENGTH OF TIME YOU HAVE TAKEN
STRENGTH THE DRUG EACH DAY THE DRUG (DAYS, WEEKS, MONTHS)
.
PAGE 5
REVIEW OF SYSTEMS
List any drug allergies:_________________________________________________
Are you allergic to Penicillin? (check one) [ ] Yes [ ] No
If you are allergic to Penicillin, please describe the type of reaction that you have
had:_________________________________________________________________
What is your usual weight?________________ What was your approximate
weight one year ago? ________________ What is your present weight? _______
YES NO
1. Have you gained or lost 5 pounds in the last two months?. . . . . . . . . . . . [ ] [ ]
2. Have you ever coughed up blood or blood streaked sputum? . . . . . . . . . [ ] [ ]
3. Do you frequently get short of breath?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] [ ]
4. Have you recently had repeated episodes of chest pain?. . . . . . . . . . . . . .[ ] [ ]
5. Are you frequently bothered with stomach pains? . . . . . . . . . . . . . . . . . . . [ ] [ ]
6. Do you frequently have “heartburn” or “indigestion”?. . . . . . . . . . . . . . . . [ ] [ ]
7. Do you have difficulty swallowing solid foods or pills?. . . . . . . . . . . . . . . [ ] [ ]
8. Do you have difficulty swallowing liquids?. . . . . . . . . . . . . . . . . . . . . . . . . .[ ] [ ]
9. Are you bothered by abdominal bloating and distention?. . . . . . . . . . . . . [ ] [ ]
10. Do you feel that you have excessIve burping or belching?. . . . . . . . . . . . . [ ] [ ]
11. Do you feel that you pass excessive gas from the rectum?. . . . . . . . . . . . .[ ] [ ]
12. Are you frequently bothered by vomiting?. . . . . . . . . . . . . . . . . . . . . . . . . . [ ] [ ]
13. Do you frequently suffer from nausea?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] [ ]
14. Have you ever vomited blood?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] [ ]
15. Have you ever passed blood in or on your bowel movements?. . . . . . . . . [ ] [ ]
16. Have you ever seen blood on the toilet tissue after a BM?. . . . . . . . . . . . . [ ] [ ]
17. Are you frequently bothered with diarrhea?. . . . . . . . . . . . . . . . . . . . . . . . . [ ] [ ]
18. Are you frequently bothered with constipation?. . . . . . . . . . . . . . . . . . . . . . [ ] [ ]
19. Have you notice a change in your bowel habits recently?. . . . . . . . . . . . . . [ ] [ ]
20. Do you experience pain or burning when you urinate?. . . . . . . . . . . . . . . . [ ] [ ]
21. Do you have difficulty getting your urinary stream started?. . . . . . . . . . . . [ ] [ ]
22. Do you awaken from sleep because you have to urinate?. . . . . . . . . . . . . . [ ] [ ]
23. Do you have frequent joint pains?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] [ ]
24. Do you suffer from headaches?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] [ ]
25. Have you ever had a stroke or convulsion?. . . . . . . . . . . . . . . . . . . . . . . . . [ ] [ ]
26. Do you often feel scared or anxious?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .[ ] [ ]
27. Have you recently felt sad, depressed, or “down in the dumps”? . . . . . . . [ ] [ ]
28. Have you recently had crying spells for no particular reason?. . . . . . . . . . [ ] [ ]
29. Do you feel tired and “worn out” most of the time?. . . . . . . . . . . . . . . . . . . [ ] [ ]
30. WOMEN: Have you had a pelvic exam in the last 2 years?. . . . . . . . . . . . . [ ] [ ]
31. WOMEN: Have you had a mammogram in the last 2 years?. . . . . . . . . . . . [ ] [ ]
32. WOMEN: Have you noticed any lumps in your breasts?. . . . . . . . . . . . . . . [ ] [ ]