Patient Intake Form Order Number Patient’s Last Name * Initial Patient’s First Name * Sex * Male Female Date of Birth * Health Insurance * OHIP OTHER OHIP Number * Private Insurance Name Phone Number * Address * City * Province * – Select Province/State – Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Postal Code * Email Address Alternate Contact Name * Relationship * Contact’s Phone Number * Referring Physician * Family Physician * Same Other Family Physician’s Name What is the reason for your visit? Please select applicable to you * 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 Vomiting Other Symptoms Hight (ft) * Weight (lb) * Do you smoke? (packs/day) * Do you drink alcohol? (glasses/week) * Do you use drugs? * Type of bowel movement * Type 1 Separate hard lumps Type 2 Lumpy and sausage like Type 3 A sausage shape with cracks on the surface Type 4 Like a smooth soft sausage or snake Type 5 Soft blobs with clear cut edges Type 6 Mushy consistency with ragged edges Type 7 Liquid consistency with no solid pieces Frequency per week * Additional Type of BM 2 Add more Type 1 Separate hard lumps Type 2 Lumpy and sausage like Type 3 A sausage shape with cracks on the surface Type 4 Like a smooth soft sausage or snake Type 5 Soft blobs with clear cut edges Type 6 Mushy consistency with ragged edges Type 7 Liquid consistency with no solid pieces per week Additional Type of BM 3 Add more Type 1 Separate hard lumps Type 2 Lumpy and sausage like Type 3 A sausage shape with cracks on the surface Type 4 Like a smooth soft sausage or snake Type 5 Soft blobs with clear cut edges Type 6 Mushy consistency with ragged edges Type 7 Liquid consistency with no solid pieces per week Additional Type of BM 4 Add more Type 1 Separate hard lumps Type 2 Lumpy and sausage like Type 3 A sausage shape with cracks on the surface Type 4 Like a smooth soft sausage or snake Type 5 Soft blobs with clear cut edges Type 6 Mushy consistency with ragged edges Type 7 Liquid consistency with no solid pieces per week Additional Type of BM 5 Add more Type 1 Separate hard lumps Type 2 Lumpy and sausage like Type 3 A sausage shape with cracks on the surface Type 4 Like a smooth soft sausage or snake Type 5 Soft blobs with clear cut edges Type 6 Mushy consistency with ragged edges Type 7 Liquid consistency with no solid pieces per week Additional Type of BM 6 Add more Type 1 Separate hard lumps Type 2 Lumpy and sausage like Type 3 A sausage shape with cracks on the surface Type 4 Like a smooth soft sausage or snake Type 5 Soft blobs with clear cut edges Type 6 Mushy consistency with ragged edges Type 7 Liquid consistency with no solid pieces per week Additional Type of BM 7 Add more Type 1 Separate hard lumps Type 2 Lumpy and sausage like Type 3 A sausage shape with cracks on the surface Type 4 Like a smooth soft sausage or snake Type 5 Soft blobs with clear cut edges Type 6 Mushy consistency with ragged edges Type 7 Liquid consistency with no solid pieces per week Past Medical History Last colonoscopy date Last Endo/Gastroscopy date Please select conditions applicable to you * 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 procedure Medical conditions not mentioned above Any Surgeries * Current Medications * Do you have a family history of cancer such as: colon, rectum, stomach, pancreas, urinary tract, ovary and uterus, prostate * Do you take Aspirin or Advil or any anti-inflammatory or blood thinners? * Yes No Allergies to medications or anesthetics * Person filling out the form * Date *
