History and Physical Form

Please complete the form below to submit your physical history. You can also download the PDF form.

Colonoscopy History/Physical Form

Patient Name

Referring/Family Doctor

Patient Date of Birth (Month/Day/Year)

Health Card Number

Should you require a prescription after pathology results, please indicate your pharmacy name, phone, fax

What procedure are you having done today?

Name and contact number for ride

Is this your first Scoping Procedure?

If no, list number of procedures you have had

Do you have a drug plan for prescriptions?

Reason for procedure

Nothing by mouth since

When was last solid food eaten

Name of bowel preparation taken

Have you been diagnosed with Anemia (low iron)

A. Medications

Any known allergies to medication?

Please list any allergies to medications

Please list all medications and dosages (including low dose aspirin and supplements)

Please list what medications you took today

B. Past Surgery

Please list any surgeries

Please list any allergies to medications

Please list all medications and dosages (including low dose aspirin and supplements)

Please list what medications you took today

C. Upper Gastrointestinal Tract Symptoms

Heartburn (acid reflux)

Bloating

Difficulty swallowing (liquids/solids)

Epigastric Pain (Stomach pain)

Melena (Black Stool)

Vomiting

Have you had any recent weight loss?

If yes, how much? (lb/kg)

Have you been tested for H. pylori?

History of hiatus hernia?

Do you take pain relievers (Advil, Naproxen)?

Do you take acid reduction medications?

Do you use recreational drugs?

Do you smoke?

Do you drink alcohol?

C. Lower Gastrointestinal Tract (Colorectal Specific Information) Symptoms

Lower abdominal pain

Constipation

Diarrhea

If yes, have you had any recent travel?

Blood in stool or rectal bleed

Mucus in stool

History of diverticulosis

History of hemorrhoids

History of Crohn’s Disease

History of Ulcerative Colitis

Have you had a stool test performed?

D. Positive Blood Tests

Have you ever had a positive test for TB?

Have you ever had a positive test for Hepatitis?

Have you ever had a positive test for HIV?

E. History of Cancer/Polyps (Please List Type of Cancer/polyps, and Family Member Affected).

Personal

Familial

If you are human, leave this field blank.

History and Physical Form

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