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________________________________
Allow yourself plenty of time to get out of bed. If you usually get up at 6 a.m. set your alarm for 5 a.m. It is usually recommended to keep a stash of crackers or dry cereal by your bed so you can put something in your stomach as soon as you wake up. This is not good for your teeth, as food s high in carbohydrates increase the risk of dental decay. If you must use crackers, brush you teeth a
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