Mark all conditions that you have had. If you have had none in a category, mark NONE.
Please mark if a relative has had any of the following.
Have any of your blood relatives had Colorectal Cancer?
Have any of your blood relatives had Colon Polyps?
CURRENTLY ACTIVE SYMPTOMS, TESTS & OTHER CONDITIONS
Select all that apply. If you have no symptoms in a category, select NONE.
HEAD, EARS, EYES, NOSE & THROAT
Have you had any of these procedures?
Please mark all surgeries you have had including the date.
OTHER PAST OPERATIONS OR MEDICAL PROBLEMS
Not noted elsewhere in this form.
PERSONAL AND SOCIAL HISTORY
How would you describe your cigarette smoking?
How many years have you (or did you) smoke?
Have you engaged in high risk behavior for sexually transmitted diseases (anal sex, unprotected sex, multiple partners)?
Please select any of these allergies you have.
If you have any additional medication allergies, please bring in list with reaction to your appointment.
If you are taking medications, please bring an accurate list at time of your appointment.
If you are not taking any medications, please indicate here: