Company Patient's Last Name * Patient's First Name * Initial Health Insurance * OHIP OTHER OHIP Number * Private Insurance Name Date of Birth * Sex * Male Female Family Physician * Referring Physician * Same Other Referring Physician's Name Home Address * Phone Number * Mobile Number Alternate Contact Name Relationship Contact's Phone Number Patient's Email Address * Pharmacy * What is the reason for your visit? Reason for the 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 Vomiting Frequency of bowel movement per week * Hight (ft) * Weight (lb) * Do you smoke? (packs/day) * Do you drink alcohol? (glasses/week) * Do you use drugs? * Past 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 procedure Medical conditions not mentioned above: Any Surgeries * Past Colonoscopy * Yes No Last Colonoscopy Past Endo/Gsatroscopy * Yes No Last Endo/Gastroscopy Current Medications * Allergies to Medications or Anesthetics * Do you have a family history of cancer such as: colon, rectum, stomach, pancreas, urinary tract, ovary and uterus, prostate * Person filling out the form * Date *
