Medical History Questionnaire Patient Name First Middle Last Email PhoneDate of Birth MM slash DD slash YYYY Today's Date MM slash DD slash YYYY Reason for Visit Colonoscopy Colonoscopy & EGD EGD Weight Loss Consultation Are you experiencing any of the following? Diarrhea Chest Pain Indigestion Change in bowel habits Anemia Difficulty swallowing Blood in stool Persistent heartburn Prostate issues Abdominal pain Positive occult stool test Positive Cologuard Chronic constipation Rectal bleeding None of the Above Please explainHeight Weight Are you allergic to any drugs, iodine, shellfish, latex, or any other allergies? Yes No AlergiesReactionsMedication List(Include any vitamins and supplements that you are currently taking)NameDoseHow Often Add RemoveFamily HIstoryAny family history of colon polyps or colon cancer? Yes No Who? Age of Onset? Any family history of stomach, esophageal, or rectal cancer? Yes No Who? Age of Onset? Social HistoryWho referred you? PhoneHave you ever had a colonoscopy or EGD before? Yes No When? MM slash DD slash YYYY What Physician? ResultsDo you have any issues with mobility?e.g. Cane Walker Wheelchair Yes No Please explainAre you able to climb two flights of stairs without stopping? Yes No Do you smoke tobacco? Yes No Previously, but quit When? MM slash DD slash YYYY How many packs do you smoke per day or per week? Do you drink alcohol? Yes No How many drinks do you have per day or per week? Are you pregnant or believe that you may be? Yes No Surgical HistoryPlease ListProcedureDate Add RemovePast Medical History(Answer yes if you ever have been diagnosed with one of the following)Coronary Artery Disease Yes No Myocardial Infarction/Heart Attack Yes No Atrial fibrillation/Arrythmia Yes No Heart valve replacement Yes No Pacemaker/Internal defibrillator Yes No COPD/Asthma/Emphysema/Use at home oxygen Yes No Stroke Yes No Seizures/Epilepsy Yes No When? MM slash DD slash YYYY Renal failure/Kidney disease Yes No Diabetes Yes No Pulmonary embolus/ DVT / Blood Clot Yes No Arthritis Yes No Barrett’s esophagus Yes No Bleeding disorder (difficulty stopping bleeding) Yes No Cancer Yes No What type? When diagnosed? MM slash DD slash YYYY Chronic constipation Yes No Colon Polyps Yes No Exposure to contagious diseases (HIV, TB, Hepatitis B, Hepatitis C) Yes No Crohn’s disease Yes No Diverticulosis/Diverticulitis Yes No Endometriosis Yes No GERD/Reflux (Heartburn) Yes No Hyperlipidemia (High cholesterol) Yes No Hypertension (High blood pressure) Yes No Hyperthyroidism (Overactive thyroid) Yes No Hypothyroidism (Underactive thyroid) Yes No Kidney Stones Yes No When? MM slash DD slash YYYY Sleep Apnea Yes No Ulcerative colitis Yes No Patient PreferencesPharmacy PhonePrimary Care Physician PhoneCardiologist PhoneEndocrinologist PhoneNeurologist PhoneNephrologist PhonePulmonologist PhoneLab Any additional questions or concerns?CommentsThis field is for validation purposes and should be left unchanged.
