Medical History

Patient Name
Date of Birth
Current Primary Care Physician
Do you drink alcohol regularly?
How many drinks per week?
Do you smoke?
How much?


Past Medical History

Surgical History

Have you ever experienced any of the following? (Select all that apply)


Recent Symptoms

Are you currently having or have had recently (Select all that apply)


Nausea/Vomiting? How Long?
Weight loss? How many pounds?
Difficulty swallowing liquids?
Difficulty swallowing solids?

Personal History

Last Colonoscopy & Where?
Last Flexible Signoidoscopy & Where?
Last Upper Endoscopy & Where?

Family History

Colon Cancer (age)
Other Cancer? What kind?




Personal Information

Name
SSI#
Date of Birth
Marital Status
Ethnicity
Race
Language
Gender

Current Residence

Street Address
City
State
ZIP

Contact Information

Home Phone
Work Phone
Cell Phone
Email Address

Emergency Contact Information

Emergency Contact Name
Phone Number
Relationship

Allergies / Medications

Medication Allergies
Medication List