Patient Information (Full Legal Name)
 
 
 
 
 
 
 
 
 
 

Patient Medical History

Mark 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

 
 
 
 
 

Musculoskeltal

 
 
 
 
 

Skin

 
 
 
 

Respiratory

 
 
 
 
 

Psychiatric

 
 
 
 
 

Blood

 
 
 

Breast

 
 
 
 

Gastrointestinal

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Have you had any of these procedures?
 
Date:  
 
Findings:  
 
Date:  
 
Findings:  
 
Date:  
 
Findings:  
 
Date:  
 
Findings:  
 
Date:  
 
Findings:  
 
Date:  
 
Findings:  
 
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)
 
1.
 
2.
 
3.
 
4.
 
 

Prescription Medications

What prescription medications are you currently taking?
(Alternatively bring in an accurate list with you)
 
1.
 
 
2.
 
 
3.
 
 
4.
 
 
5.
 
 
6.
 
 
7.
 
 
8.
 
 
9.
 
 
10.
 
 
11.
 
 
 

Over-The-Counter Medications

What over-the-counter medications are you currently taking?
(e.g., Aspirin, Motrin, Tagamet-HB, Vitamins, etc.)
 
1.
 
 
2.
 
 
3.
 
 
4.
 
 
5.
 
 
 

Physicians

 
Which physician referred you?
 
 
Who is your primary care doctor?
 
 

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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 421
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.