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Patient Questionnaire
Please fill this form accurately. The contents of the form are confidential.
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Name
*
First
Middle
Last
write “N/A” if not applicable
Health Care Number
*
Cell Phone # (Or preferred contact #)
*
Home Phone #
Email
Age
*
Height (cm)
*
Weight (kg)
*
Pharmacy Name
*
Primary Reason for Visit
Symptoms (check if applicable)
*
Abdominal Pain
Nausea
Vomiting
Vomiting Blood
Heartburn
Difficulty or Painful Swallowing
Loss of Appetite
Weight Loss in Past 6 Months
Stool
Diarrhea
Constipation
Abdominal Bloating
Rectal Bleeding
Passing Black Stool
None of the Above
Type of Pain
*
Stabbing/Sharp
Dull
Weight Loss in Past 6 Months
*
Specify how many kg, and if it was intentional or not
Stool
*
Indicate how many times per day
Date of Last Colonoscopy
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
MM
1
2
3
4
5
6
7
8
9
10
11
12
YYYY
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Leave blank if not applicable
Date of Last Gastroscopy
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
MM
1
2
3
4
5
6
7
8
9
10
11
12
YYYY
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Leave blank if not applicable
Past Medical History (please list)
*
“N/A” if not applicable
Past Surgical History (Please List)
*
“N/A” if not applicable
Medication (please list)
*
“N/A” if not applicable
Medication Allergies
*
“N/A” if not applicable
Occupation
Alcohol Use
*
Yes
No
Please Specify How Often per Week
*
Cigarette Use
*
Yes
No
Please Specify How Often Per Day, And For How Many Years
*
Family Medical History (check if applicable)
Colon Cancer
Colonic Polyps
Stomach Cancer
Crohn’s Disease/Ulcerative Colitis
Celiac Disease
Colon Cancer
Relationship to Patient
*
Mother
Father
Sister
Brother
Cousin
Other
Age of Diagnosis
*
Other
*
Colonic Polyps
Relationship to Patient
*
Mother
Father
Sister
Brother
Cousin
Other
Age of Diagnosis
*
Other
Stomach Cancer
Relationship to Patient
*
Mother
Father
Sister
Brother
Cousin
Other
Age of Diagnosis
*
Colon Colitis And
Other
Crohn’s Disease/Ulcerative Colitis
Relationship to Patient
*
Mother
Father
Sister
Brother
Cousin
Other
Age of Diagnosis
*
Other
Celiac Disease
Relationship to Patient
*
Mother
Father
Sister
Brother
Cousin
Other
Age of Diagnosis
*
Other
Describe any other information you feel may be relevant:
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