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  • Patient Information

  • Patient Questionnaire: Gastroenterology

  • Today System
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Patient Medical History

  • Do you have any allergies to medication?*
  • If you answered yes to allergies to medication, please select all that apply:
  • In the course of the last year, have you taken any type of steroid or cortisone?*
  • Do you take any anticoagulants? (e.g. aspirin, coumadin, etc.)*
  • Do you or have you ever experienced any cardiovascular conditions/illnesses?*
  • Select all conditions that apply?
  • Do you or have you ever experienced any respiratory conditions/illnesses?*
  • Which conditions?
  • Do you or have you ever experienced any digestive conditions/illnesses?*
  • Which conditions?
  • Do you or have you ever experienced any endocrine conditions/illnesses?*
  • Which conditions?
  • Do you or have you ever experienced any neurological conditions/illnesses?*
  • Which conditions?
  • Do you or have you ever experienced any hematological conditions/illnesses?*
  • Which conditions?
  • Do you or have you ever experienced any urological conditions/illnesses?*
  • Which conditions?
  • Do you or have you ever experienced any musculoskeletal conditions/illnesses?*
  • Which conditions?
  • Do you or have you ever experienced any dental/oral conditions/illnesses?*
  • Which conditions?
  • Do you currently have any of the following deficiencies/impairments?
  • Do you snore? Louder than talking or loud enough to be heard through a closed door, or often feel fatigued or sleepy during the day, or has someone observed you stop breathing in your sleep?*
  • Do you suffer from high blood pressure?*
  • Is your neck circumference greater than: 43 cm/17 in (Male), 41 cm/16 in (Female)?*

  • Habits

  • Do you take any recreational drugs?*
  • Which ones and how often?
  • Do you drink alcohol?
  • Do you smoke?

  • Emergency Contact

    The person who will accompany you on the day of your procedure. Note that for safety reasons, you will not be permitted to drive or to leave unaccompanied after your surgery.
  • Format: (000) 000-0000.

  • Pharmacy Contact

    We need to know which pharmacy you regularly shop at, so we can coordinate with them regarding your care
  • Format: (000) 000-0000.

  • Surgical History

    The patient's history of surgical procedures carried out
  • Rows
  • If you have had previous surgery, were there any adverse reactions to the anaesthesia used?*
  • What kind of reactions?

  • Medical Insurance

    The patient's residency and medical insurance information
  • Are you a resident of Canada?*
  • Medical Card Expiration Date
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  • Electronic Communication and Security

  • Should be Empty: