Microsoft word - precolonquestions

Express: Jay A. Cherner, M.D.
Gastroenterology Consultants, P.C.
MEDICAL QUESTIONNAIRE FOR SCREENING
COLONOSCOPY
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.___________________________
______________________________________________________________________________________
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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
stop?__________________________________________________________________________________
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:
Anal
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:

Source: http://www.drjaycherner.com/client_files/file/PRECOLONQUESTIONS.pdf