Patient's Assessment Form Name Name Name Name Date Of Birth OHIP No Family Physician Height Weight Occupation Address Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Telephone Cell Phone Email Emergency Contact Name Emergency Contact Number Appointment Date Select Advance Endoscopy & Specialist Center Region MississaugaTorontoBowmanville Why are you here today? Abdominal Pain Fever Vertigo (Dizziness) Food Intolerance Appetite loss Dysphagia (Difficulty Swallowing) Lactose Intolerant (Unable to eat dairy) Nausea Vomiting Hematemesis (Vomiting blood) Weight Change Constipation Need for laxatives Enema Use Diarrhea Crohns Irritable Bowel Syndrome Colitis Celiac Disease Diverticula Cancer Polyps Bowel Surgery Rectal Pain Blood Incontinence Mucus Discharge Pus Melena (black tarry feces) Heart Burn Acid Reflux Belching Bloating Anemia OtherOther Please record all medications Medication Name Daily Dose Start Date Date of Most Recent Dose Add Remove Do you have any drug, food or latex allergies? Yes No please complete the following: Name of Drug Type of Reaction Name of Food Type of Reaction Add Remove Are you on COUMADIN (WARFARIN) or any blood thinners? Yes No Have you had a prior colonoscopy or endoscopy? Yes No Date of Procedure Location of Procedure Results Please list all operations during which you received general or other type of anesthetic/sedation? Name Of Operation Year Add Remove . Have you or any member of your family had a reaction to local/general anesthetic/sedation? (not including nausea or vomiting)? Yes No Please provide details Do you consume alcohol on a daily basis? Yes No Number of years How much do you consume on average in a week? Have you ever smoked or use nicotine? yes No Number of years How much average per day? When did you quit? (if applicable) Do you use recreational drugs? (I.e. marijuana, cocaine) Yes No If yes, please provide details: Do you consume caffeine (i.e. coffee, tea) on a daily basis? Yes No Number of years Have you ever been diagnosed with or suspected to have any of the following by a Physician: Communicable diseases (Hepatitis/HIV Aids) Heart Disease(Heart Attack, Angina, Heart Failure Irregular Heart Beat Shortness Breath Asthma Sleep Apnea High Blood pressure High Cholesterol Bleeding Tendency Cancer (Please specify) EpilepsyDepression/Emotional Stress Arthritis? Malignant Hyperthermia? Diabetes Mellitus Insulin or Pills Are you Pregnant? If yes, please explain and indicate year diagnosed)/ If unsure, please explain Do you have a family history of: Cardiovascular Disease Yes No Polyps Yes No Cancer Yes No If yes, please specify: Relation Cancer Of The At Age Add Remove If you are human, leave this field blank. Submit
