PatientLink

Patient Medical History

* Required Information
Select all conditions that you have had.  If you have had none in a category, mark None.

*Gastrointestinal Conditions

 
 

*Non-Gastrointestinal Conditions

 
 

Cancer

 
 

Family History

Please mark if a relative has had any of the following.
Have any of your blood relatives had Colorectal Cancer?
 
Mother
Age of Onset:
Father
Age of Onset:
Sister
Age of Onset:
Brother
Age of Onset:
Daughter
Age of Onset:
Son
Age of Onset:
Other
Age of Onset:
Have any of your blood relatives had Colon Polyps?
 
Mother
Age of Onset:
Father
Age of Onset:
Sister
Age of Onset:
Brother
Age of Onset:
Daughter
Age of Onset:
Son
Age of Onset:
Other
Age of Onset:

Currently Active Symptoms, Tests & Other Conditions

Select all that apply.  If you have no symptoms in a category, select None.
 

*General

 

*Head, Ears, Eyes, Nose & Throat

 

*Cardiovascular

 
 

*Genitourinary

 
 

*Neurological

 
 

*Endocrine

 

*Musculoskeletal

 

*Skin

 
 

*Respiratory

 

*Psychiatric

 

*Blood

 

*Breast

 
 

*Gastrointestinal

 
Have you had any of these procedures?
*Colonoscopy
Date:  
Findings:  
*Flexible Sigmoidoscopy
Date:  
Findings:  
*Upper Endoscopy
Date:  
Findings:  
*ERCP (endoscopic retrograde cholangiopancreatography)
Date:  
Findings:  
*EUS (endoscopic ultrasound)
Date:  
Findings:  
*CT scan of abdomen or GI tract (past 6 months)
Date:  
Findings:  
*Ultrasound of abdomen or GI tract (past 6 months)
Date:  
Findings:  
*Dexa Scan
Date:  
Findings:  

Personal and Social History

 
*Do you live alone?

Alcohol Use

*Do you consume alcohol?
*Average number of drinks per week (now or in the past)?

Tobacco Use

*How would you describe your cigarette smoking?
*How many packs per day do you (or did you) smoke?
*How many years have you (or did you) smoke?
*Do you use other tobacco products?

Caffeine Use

*How many caffeinated beverages do you consume per day?

Other

*IV drug use or other recreational drug use?
*Have you engaged in high risk behavior for sexually transmitted diseases (anal sex, unprotected sex, multiple partners)?
*Have you ever had a blood transfusion?
*Have you had any recent foreign travel?
*Do you have any body piercings?
*Do you have any tattoos?

*Surgeries

Please mark all surgeries you have had including the date.
 

Other Past Operations or Medical Problems

...not noted elsewhere in this form.
 
 

Allergies

*Please select any of these allergies you have.
 

Medication Allergies

Please list the medications or injections that have given you bad reactions.  If possible, include your reactions.
(e.g., hives, welts, rash, itching, headaches, nausea, diarrhea, passed out, shock, shortness of breath)
 
 
 
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4.
 

Physicians

Which physician referred you?
Who is your primary care doctor?
 
 
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.