Patient History Questionairre

How long have you had this problem?

	days	weeks	months	years
enter number

How severe is the problem?
Allergies
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:

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 *
Date of last colonoscopy, leave blank if you have not had one

Month Day Year
Date
Findings on last colonoscopy
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 *

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

Clear
Please verify that you are human *
Should be Empty: