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Patient Information

*Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.
 
 

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

 

Muskuloskeletal

 

Skin

 

Respiratory

 

Psychiatric

 

Blood

 

Breast

 

Gastrointestinal

 
Has your stool tested positive for blood in the past 6 months?
Have you had any of these procedures?

Surgeries

 

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

 

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?
Do you live alone?

Allergies

 

Please select any of these allergies you have.

If you have any additional medication allergies, please bring in list with reaction to your appointment.

 

Medications

 

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:

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