"*" indicates required fields PATIENT MEDICAL HISTORYName*Todays date MM slash DD slash YYYY Height*Weight*Date of birth*Age*Reason for coming to see the doctor today?*History of Present IllnessDo you have anal pain?* Yes No Do you have pain after a bowel movement?* Yes No Do you feel rectal itching or burning?* Yes No How long have you had the pain?Have you had a change in bowel movements?* Yes No Number of bowel movements per week?*What changed?Do you have diarrhea?* Yes No Are you constipated?* Yes No Do you require laxatives or enemas?* Yes No Do you have abdominal pain?* Yes No Past Medical History (Chronic Illnesses)*Previous Colon ScreeningFlexible Sigmoidoscopy (date)Cologuard (date)Colonoscopy (date)Past Surgical History (Please list all operations you have had and the dates of occurrences)*Medication ListPlease list all medications/supplements you are taking and doses. Include over-the-counter medications.AllergiesPlease list any medications you are allergic to and explain the reaction to the medication.Personal HabitsDo you smoke tobacco? Yes No How much per week?Did you quit?How long ago?Do you drink alcohol? Yes No How much per week?Did you quit?How long ago?Do you vape or smoke electronic cigarettes? Yes No Do you use marijuana? Yes No Do you exercise? Yes No How much?How many days per week?Family HistoryPlease list your family member and the associated diseases.Colon Cancer - Family memberRectal Cancer - Family memberPolyps - Family memberOther GI diseasesNo family history of any of these diseases None Review of SystemsDo you currently have or have a history of the following? Please check all that apply. If you do not check a box, we assume the answer is NO.General Fever Significant Weight Change Hemotologic Anemia Bleeding Disorder Clotting Disorder Blood Thinner Use Oncologic Chemotherapy Radiation When?Respiratory Sleep apnea Productive cough Shortness of breath Asthma Dermatologic Rash Skin Cancer Urologic Frequent urination Urinary incontinence Cardiovascula Low blood pressure High blood pressure Irregular heartbeat Heart murmur Heart attack Mitral valve prolapse Swollen feet Abnormal stress test Pacemaker Reproductive Prostate gland problems Difficulty urination Penile discharge Irregular menstruation Vaginal spotting Vaginal discharge Endometriosis Abdominal / GI Hernia Nausea Vomiting Reflux Peptic Ulcer Jaundice Blood in stool Diarrhea Constipation Type of hernia?Neurologic / Psychiatric Stroke Seizure Fainting or blackouts Depression Anxiety Rheumatologic Arthritis Pregnancies# of pregnancies# of vaginal deliveries# of C-sections# of miscarriagesDates of children’s birthsPhoneThis field is for validation purposes and should be left unchanged.
