Microsoft word - precolonquestions

Express: Jay A. Cherner, M.D.
Gastroenterology Consultants, P.C.
Today’s Date:________________ Name:____________________________________ Age:_____ Date of Birth:________ Sex: M / F Occupation:__________________________ The reasons for the colonoscopy are (check all that apply): Screening (age over 50) __________ Family history of colon cancer __________ Polyps removed at a previous colonoscopy __________ Previous colorectal cancer __________ Hidden blood found in stool __________ Blood test abnormality __________ Symptoms: Rectal bleeding __________ Change in bowel habits __________ Constipation __________ Diarrhea __________ Have you ever had a colonoscopy before?___________ If yes, please complete below: Circle any years when polyps were found & removed Have you ever had an upper endoscopy (EGD, gastroscopy)? ______________________ List all prescription medications you are now taking (include doses). If you are not sure about name or
dosage, please bring the medicine bottles with you to office consultation.___________________________
List all non-prescription medications you have taken within the past two weeks or take on a frequent
basis. Include aspirin (with dose), ibuprofen, Advil, Motrin, Alleve, naproxyn, vitamin E, laxatives,
suppositories, and enemas. Specify how often you take each of these.
Do you use laxatives?_______ Which ones?__________________________ How often?_____________ Circle any of the following blood-thinning medications that you may be taking: Coumadin (warfarin),
Plavix, Aggrenox, Pletal. Who is the prescribing physician?__________________________________
For what conditions are you taking this blood thinner?__________________________________________
List any allergies to medicines_____________________________________________________________
If you have had a colonoscopy previously, did you have any problem with the bowel prep?_____________________ With the sedation?_____________________________ Any problems afterwards?___________________________________________________________________________ Do you have difficulty breathing (asthma, COPD, emphysema)? ______________________ Do you use supplemental oxygen?__________ Have you ever had a problem with a sedative or anesthesia?____________________________________ Has anxiety been a major problem recently?_________________________________________________ Are there any problems with your kidney function (renal failure)?_______________________________ Have you had problems with low or high potassium or calcium in your blood?_____________________ Do you have an implantable defibrillator?_______ Do you have a pacemaker?_____________________ Have you been troubled by chest pain, chest pressure or smothering in the past year?______ Have you ever had a heart attack?__________________ Do you have atrial fibrillation? ________ Do you have any other abnormal heart rhythm? _________Are
you aware of any problem with the valves of your heart?_______________________________________
Do you smoke cigarettes?________ How many per day?________ For how many years?________
If you no longer smoke, how much did you smoke, for how many years, and when did you
Please circle the number of alcoholic beverages you typically consume in one week:
none 1 to 3 4 to 7 8 to 14 15 to 21 22 to 28 more than 28 If you no longer drink, how much did you drink, for how many years, and when did you stop?__________________________________________________________________ Has either a parent, brother, sister, child or grandparent had cancer of colon or rectum?__________ If yes, what relationship and at what age was that person diagnosed? ____________________________________ Have parents or siblings had colon polyps? _____ Who? ________________________________________ Has either a parent, sibling or child had any of the following (indicate relationship): Breast cancer_____________________ Sprue (celiac disease)__________________ Ulcerative colitis______________________ Please list all previous surgeries (include approximate dates):_________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Other than for surgeries, have you ever stayed overnight in a hospital?_____ If so, please give the medical conditions that were treated and approximate dates:____________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Have you ever been diagnosed with cancer?_____ If yes, please provide primary organ involved and date first diagnosed: _________________________________________________________________________ Please check any of the listed gastrointestinal problems that you have had. Circle those
that are active at this time:
Frequent abdominal pain_____ Adhesions_____ Regurgitation_____ My typical bowel pattern is: (f) 3 or more per day (give number)_____ Please circle those problems that have been present in the past year: If you think you have a significant medical problem that was not covered on this form, please list below:



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