Nurse-Call Colonoscopy Assessment

Patient Information

Primary Insurance Information

If there are multiple phone numbers, seperate them using ','

Secondary Insurance Information

If there are multiple phone numbers, seperate them using ','

Family History

Do any blood relatives have any of the following?
Disease Yes No
Crohn's Disease or Ulcerative Colitis
Diabetes Mellitus
Gallbladder Disease
Colon Cancer/Colon Polyps
Ovarian/Uterine/Breast Cancer
Esophageal Cancer
Stomach Cancer
Other Cancers
Pancreas/Liver Disease/Cirrhosis
Early Heart Disease
Peptic Ulcer Disease
Lupus or Sprue
Personal Health Habits
Activity Yes No
Do you exercise routinely?
Cigarette or cigar use?
Chewing tobacco/pipe?
Use alcoholic beverages?
History of alcohol abuse?
Recreational drug use?
Personal Diet Requirements


If yes, list:
Allergy Describe Reaction

Please list all medications you are currently taking or have taken in the last 30 days including: vitamins, birth control pills, herbal medications, etc. List actual dosages and frequency below:

Medication Dosage Frequency
Hospital/Surgical History
Type/Reason Surgeon Place of Surgery Date (if known)
Endoscopic History

Recent Studies

Review of Current Symptoms
Constitutional Yes No
Fever or Chills
Night Sweats
Appetite/Weight Yes No
Loss of appetite
Loss of weight
Increase in weight
Gastrointestinal Yes No
Painful swallowing
Food sticking in throat or choking
Abdominal pain
Blood in stool
Black Stools
Loss of control of bowel movements
Pulmonary Sumptoms Yes No
Shortness of breath
Heart Symptoms Yes No
Chest pain
Irregular heart beat or palpations
Heart Murmur
Swelling/edema of feet/ankles
Nervous System Yes No
Numbness/tingling of legs/hands
Feelings/Emotions Yes No
Trouble Sleeping
Feelings of tension, nervousness or anxiety
Feelings of depression, blue or sad
Head, Eyes, Nose, Throat Yes No
Eye Disease
Sinus Problems
Mouth Disease (dry mouth/sores in mouth)
Genio-urinary Yes No
Pain or burning with urination
Leaking urine
Blood in urine
Kidney stones
Musculoskeletal Yes No
Back pain or muscles aching
Pain swelling or stiffness in joints
Skin Yes No
Skin rash or condition
Hematologic/Endocrine Yes No
Enlarged lymph nodes
Easy bruising or bleeding
Hot/cold intolerance
Exposures in the past year Yes No
Well water
Foreign travel
Camping, fishing, hunting, ticks
Chemical exposures
Past medical history Yes No
Gastric/duodenal ulcers
Pancreas disease
Liver disease
Thyroid disease
Stroke or seizure
Heart disease or heart attack
Valvular heart disease
Pacemaker or defilbrillator
Stent Placements
Lung disease/asthma
Kidney disease/dialysis
Anemia/blood transfusion
Blood clots (DVT/PE)
Any sexually transmitted diseases
Tuberculosis or positive PPD
Glaucoma (high pressure in eyes)
Psychiatric disorders