OREC Intake Form Notify Patient's Last NamePatient's First NameInitialHealth Insurance-Select-OHIPOTHEROHIP NumberPrivate Insurance NameDate of BirthSex-Select-MaleFemaleFamily PhysicianReferring Physician-Select-SameOtherReferring Physician's NameHome AddressPhone numberMobile NumberEmail AddressAlternate Contact NameRelationshipContact's Phone NumberPharmacyWhat is the reason for your visit Screening Colonoscopy Anal pain Belching Bitter tongue Black stool Bringing up food Change in bowel movements Diarrhea Excessive gas Constipation Cough Difficulty swallowing Foul mouth smell Gurguling and rumbling in the stomach Heartburn Incomplete evacuation of stool Incontinence of stool Indigestion Left lower abdominal pain Loss of appetite Migrating abdominal pain Mid abdominal pain Nausea Night rectal pain Need to use laxative Pain while passing stool Rectal bleeding Rectal mucus discharge Right lower abdominal pain Sore throat Straining when passing stool Upper abdominal pain VomitingHight (ft)Weight (lb)Do you smoke? (packs/day)Do you drink alcohol? (glasses/week)Do you use drugs?Frequency of bowel movement per weekPast Medical History None Abdominal aortic aneurysm Anal fissure Anal fistula Appendectomy Asthma Barrett's esophagus Bleeding disorder Brain aneurysm Cardiac myopathy Chest pain Celiac disease Cesarean section Cirrhosis Crohn’s disease Cholecystectomy Defibrillator Diabetes Dyalisis Emphysema Fatty liver Fistulotomy Fundoplication Gastric bypass Heart Attack Heart bypass Hemorrhoidectomy Hemorrhoid rubber band ligation Hepatitis B Hepatitis C High blood pressure High Cholesterol Hip Replacement Hysterectomy IBS Inguinal hernia repair Kidney failure Knee replacement Low hemoglobin Lung disease Microscopic colitis Mini stroke Overactive thyroid Pacemaker Palpitation Shortness of breath Sleep apnea Sleeve procedure Stents Stroke Supraventricular tachycardia Ulcerative colitis Underactive thyroid Ventricular Fibrillation Whipple procedureMedical conditions not mentioned above:Any SurgeriesPast Colonoscopy Yes NoLast ColonoscopyColonoscopy findingsPast Endo/Gastroscopy Yes NoLast Endo/GastroscopyGastroscopy findingsCurrent MedicationsAllergies to Medications or AnestheticsDo you have a family history of cancer such as: colon, rectum, stomach, pancreas, urinary tract, ovary and uterus, prostatePerson filling out the formDateSubmit
