Colon and rectal clinic, p

Colon and Rectal Clinic, P.A.
Patient Name: ________________________ Age: __________ Date of Visit: _________
Height: _______________ Weight: _______

(Please list any illness you have had, and the dates of their occurrence)
_____________________________________ ________________________________
_____________________________________ ________________________________
_____________________________________ ________________________________
PREVIOUS COLON SCREENING (Please list the most recent colon screenings you have undergone
and the dates of their occurrence)
Flexible Sigmoidoscopy _________________ Colonoscopy ___________________
Barium Enema ________________________ _______________________________
PAST SURGICAL HISTORY (Please list all operations you have had and the dates of occurrence)
_____________________________________ ________________________________
_____________________________________ ________________________________
_____________________________________ ________________________________
MEDICATION (Please list all medications that you are currently taking and their doses. Please include
over-the-counter and herbal medications) Please note if you are on the following specifically:
__________________________________________ Plavix  Coumadin/warfarin  Ticlid  Aspirin 
____________________________________ __________________________________
____________________________________ __________________________________
ALLERGIES (Please list any medication you are allergic to and explain the reaction to the medication)
No Known Drug Allergies______________ ________________________________
_____________________________________ ________________________________
FAMILY HISTORY (Please list your family member and the disease associated)
Colon Cancer ________________________ Other__________________________
Rectal Cancer ________________________ ________________________________
Polyps ______________________________ ________________________________
REVIEW OF SYSTEMS (Do you currently have or had a history of the following? Please check all
that apply. If you do not check the box, we assume that the answer is no.)
General Cardiovascular
Female Reproductive
Recurrent fever High blood pressure Urologic
Eye, Ear, & Throat
Male Reproductive
Abnormal stress test Prostate gland problems pregnancies ______ Personal Habits
Difficulty swallowing Nausea/vomiting Diabetes Asthma ______________________ Hematologic Peptic Ulcer Hormonal abnormalities
Anemia Jaundice
Primary Care Doctor
Oncologic Rash
Other Physicians
I have reviewed the above information with the patient on this date. All boxes which are not checked are either negative or N/A. Physician’s Signature________________________________


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