California Advanced Gastroenterology

"Our bowels are at their best when they function silently and with only intermittent recognition.” 
Sherwood Gorbach, 1974

 

 

 

Easy Access Colonoscopy
    Medical History

 
  Date
                (mm/dd/yy)

  Name   
                (first mi last)                                                       

  Age 

  Primary or Referring Physician
 

  Medical Problems (check those which apply)

         

High Blood Pressure 

            Diabetes Mellitus          
  Asthma, Emphysema   High Cholesterol           
  Stroke or TIA Thyroid Problems          
Arthritis                          Seizures                   
Anxiety Depression

Heart Attack

Congestive Heart Failure
Heart Murmur Arrhythmia
Bleeding Disorder Headaches
Cancer If so, what type and when?
Other conditions or illnesses not mentioned above

  Prior Surgery (type of surgery and approximate year—most recent first if possible)

    1.

    2.

    3.

    4.

    5.

    6.                            

  Current Medications (names only, doses not necessary)

    1.        5.

    2.        6.

    3.        7.

    4.        8.

 

  Social History:  
 
     Do you smoke?  yes    no      
               If so, how much per day?

    Do you drink alcohol, including wine or beer?  yes  no
                If so, how much do you drink per week? 

    Occupation:

    Marital status:   S    M   D   W   Other

  

  Family History: (immediate family members only)

     Of liver disease?   yes  no  
               If yes, please specify

     Of stomach, esophageal or pancreatic cancer?  yes  no 
               If yes, please specify

 

  Now...about your colon:

    Have you ever had a colonoscopy before?  yes  no  don't know
                If yes, when (approximately) and by whom?

    Have you had a sigmoidoscopy before?     yes  no  don't know
                If yes, when (approximately)? 

    Have you been diagnosed with colon polyps before?  yes  no

    Do you have a first degree relative (parent, sibling or child) previously diagnosed with colon cancer or polyps?  yes  no  don't know
                If yes, please explain:

    Has there been any change in your bowel habits, either in stool frequency, consistency, or shape/caliber?  yes  no
                If yes, briefly explain:

    Have you noticed blood on the toilet tissue within the past year?       yes  no

    Have you noticed blood in the toilet bowl or in/on your stools within the past year?  yes  no

    Have you experienced an unintentional weight loss within the past year?  yes  no

    Do you experience any abdominal discomfort on a regular basis?  yes  no

 

  Just a few last questions:

    1. Do you take aspirin, anti-inflammatory pain relievers, or arthritis medications, other than Tylenol?  yes   no  
               If so, which ones and  approximately how often?        

    2. Have you had any recent tests (blood, scans, or x-rays) that you believe would help us in your care?  yes no.
              If so, please ask your doctor to fax them to us (863-1234) and/or inform our office staff.

    3. Have you seen another gastroenterologist before?  yes   no .
              If so, please note the doctor's name and when you last saw him or her