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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.
 
 

Reason for Visit

 

Your Medical History

 

Gastrointestinal Conditions

 
 
Other:

Non-Gastrointestinal Conditions

 
 
Other:

Cancer

 
 
Other:

Family History

 
Have any of your blood relatives had Colorectal Cancer?
 
Grandparent
 
Age relative developed condition, if known:
Parent
 
Age relative developed condition, if known:
Brother / Sister
 
Age relative developed condition, if known:
Child
 
Age relative developed condition, if known:
Aunt / Uncle
 
Age relative developed condition, if known:
 
Other:

Patient Status

 
Marital status:
Do you live alone?

Alcohol Use

Do you consume alcohol?
 
Average number of drinks per week?

Tobacco Use

How would you describe your cigarette smoking?
How many packs per day?
For how many years?
Do you use other tobacco products?

Caffeine

How many caffeinated beverages do you consume per day?
Recent foreign travel?
IV drug use or other recreational drug use?
Have you engaged in high-risk behavior for sexually transmitted diseases (e.g., anal sex, homosexual activity, multiple sex partners, etc.)?
Have you had a blood transfusion?
Do you have a tattoo(s)?
Do you have a body piercing(s)?

Current Conditions

 

Do you currently have any of these symptoms or conditions? select all that apply.  If no symptoms, select "None".

 

Gastrointestinal

Has your stool tested positive for blood?
Have you ever had an x-ray, CT or ultrasound of your abdomen or GI tract?
 

General

 

Neurological

 

Cardiovascular

 

Respiratory

 

Genitourinary

 

Endocrine

 

Females

 

Pschosocial

 

Skin

 

Bone & Joint

 

Blood

 

Eyes

 

Ears / Nose / Throat

 
Do you have an advance directive?
 
Do we have a copy?

Surgeries

 
 
Other:

Other Past Medical Problems

 
Other:

Procedures

 

Please indicate if you have had any of the following:

Date:
Findings:
Date:
Findings:
Date:
Findings:
Date:
Findings:

Allergies

 

Please indicate if you have allergies to any of the following:

 
 
Other:
Please list any medications or injections that have given you bad reactions.  If possible, include your reactions (e.g., hives, welts, rash, itching, headaches, nausea, diarrhea, fainted, shock, shortness of breath, etc...).
 
Please list any foods that have given you bad reactions.  If possible, include your reactions (e.g., hives, welts, rash, itching, headaches, nausea, diarrhea, fainted, shock, shortness of breath, etc.)

Medications

 

Include prescription and over the counter medications (e.g., aspirin, Advil, BC Powder©, Motrin, Tagamet-HB, vitamins, supplements, herbs, etc...).

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Occupation:
Referring MD:
Last Menstrual Period:
Primary MD / OB-GYN:

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