Advance Endoscopy & Specialist Center,
info@advanceendoscopy.com
Mon - Sat: 7:30 AM - 04:00 PM
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Flexible Sigmoidoscopy
Instruction
General Information
Irritable Bowel Syndrome (IBS)
Constipation
Diverticular Disease
Anal Stenosis
Anusitis/Pruritis Ani
Anal Fissures, Fistulas
and Lesions
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Mon - Sat: 7:30 AM - 04:00 PM
info@advanceendoscopy.com
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Patient’s Assessment Form
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Patient’s Assessment Form
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
Mississauga
Toronto
Bowmanville
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
Other
Other
Please record all medications
Medication Name
Daily Dose
Start Date
Date of Most Recent Dose
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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
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If you are human, leave this field blank.
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