Patient History Questionairre
Ganesh Deshmukh MD & Adeyemo Adewunmi MD & Vishnu Pemmaraju MD
Today's Date
-
Month
-
Day
Year
Date
Name
First Name
Middle Name
Last Name
Date Of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Reason For Visit
How long have you had this problem?
days
weeks
months
years
enter number
1
2
3
4
5
6
7
8
9
10
11
more than 11
1
2
3
4
5
6
7
8
9
10
11
more than 11
1
2
3
4
5
6
7
8
9
10
11
more than 11
1
2
3
4
5
6
7
8
9
10
11
more than 11
How severe is the problem?
Please Select
mild
moderate
severe
Allergies
Please Select
none
penicillin
sulfas
Latex
Other antibiotics
Other Drugs
Please list your medications
*
none
Do you take blood thinners?
*
Eliquis
Plavix
Coumadin
Other, please list above
none
Anorectal Problems:
*
Blood in Stool
Burning after BM
Pain after BM
Continuous Anorectal Pain
Protrusion
Itching
Leakage of Mucous or Stool
No Anorectal Problems
Abdominal symptoms:
*
Nausea
Vomiting
Bloating
Abdominal Pain
Diarrhea
Constipation
Heartburn
Difficulty Swallowing
No Abdominal Symptoms
Abdominal Pain:
Mild
Moderate
Severe
Cramping
Continous
Abdominal Pain Location:
Right sided
Left sided
Mid abdomen
Upper abdomen
Mid abdomen
Lower abdomen
Cardiovascular Problems
*
chest pain
shortness of breath
arrythmias
none
Respiratory Problems
*
cough
blood in sputum
asthma attacks
none
Neurological Problems
dizziness
weakness in arms or legs
seizure disorder
loss of sensation in any part of body
none
Urinary symptoms
cloudy urine
blood in urine
passing air when urinating
none
Liver disease
*
jaundice
generalized itching
biliary colic
bleeding disorder
none
Musculoskeletal problems
joint pains
lumps over arms or legs
difficulty walking
none
Medical History
*
Bleeding Disorders
Hypertension
Chronic lung disease
Stroke
colitis
GERD
Chronic kidney disease
Organ transplant
Coronary artery disease
Crohn's disease
Diabetes
Past cancers
Other illnesses, please enter in box below
None
Other illnesses
Do you have a pacemaker or Defibrillator
*
Please Select
Yes
No
Date of last colonoscopy, leave blank if no previous colonoscopy
-
Month
-
Day
Year
Date
Findings on last colonoscopy, enter N/A if no previous colonoscopy
Please Select
N/A
normal
diverticulosis
colon polyps
colon cancer
rectal cancer
colitis
Crohn's disease
Other, please specify in next box
Other findings on colonoscopy
Previous surgical history
*
colectomy
abdominal hernia repair
hysterectomy
cholecystectomy
bladder or prostate surgery
Colonoscopy
Upper gastrointestinal endoscopy
Other, please specify in next box
None
Other surgery
none
Family History of Cancers
*
Parent
Sibling
Any relative
Colon or Rectal Cancer
Yes
No
Yes
No
Yes
No
Breast Cancer
Yes
No
Yes
No
Yes
No
Gastric Cancer
Yes
No
Yes
No
Yes
No
Ovarian Cancer
Yes
No
Yes
No
Yes
No
Prostate Cancer
Yes
No
Yes
No
Yes
No
Other Cancers
Yes
No
Yes
No
Yes
No
No cancer history
Yes
No
Yes
No
Yes
No
Social History
*
current smoker
former smoker
recreational drugs
social alcohol consumption
Daily alcohol consumption
none of the above
Activity
*
sedentary
moderately active
vary active lifestyle
Sexual Preferences
*
not sexually active
Opposite sex
Same sex
Other
Signature
Please verify that you are human
*
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