Colon and rectal clinic, p
Colon and Rectal Clinic, P.A.
Patient Name: ________________________ Age: __________ Date of Visit: _________
Height: _______________ Weight: _______
PREVIOUS ILLNESSES (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
Neurologic/Psychiatric
Recurrent fever High blood pressure
Urologic
Eye, Ear, & Throat
Male Reproductive
Abnormal stress test Prostate gland problems pregnancies ______
Personal Habits
Respiratory
Abdominal/GI
Endocrine
Difficulty swallowing Nausea/vomiting
Diabetes Asthma ______________________
Hematologic Peptic Ulcer Hormonal abnormalities
Anemia Jaundice
Rheumatologic
Primary Care Doctor
Dermatologic
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________________________________
Source: http://www.crchouston.com/pdf/156_Patient_History-Physical.pdf
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