Advance Endoscopy & Specialist Center,
info@advanceendoscopy.com Mon - Sat: 7:30 AM - 04:00 PM
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Patient’s Assessment Form

Patient's Assessment Form
Name
Name
Address
Address
City
State/Province
Zip/Postal
Why are you here today?

Please record all medications

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Do you have any drug, food or latex allergies?

please complete the following:

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Are you on COUMADIN (WARFARIN) or any blood thinners?
Have you had a prior colonoscopy or endoscopy?

Please list all operations during which you received general or other type of anesthetic/sedation?

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. Have you or any member of your family had a reaction to local/general anesthetic/sedation? (not including nausea or vomiting)?
Do you consume alcohol on a daily basis?
Have you ever smoked or use nicotine?
Do you use recreational drugs? (I.e. marijuana, cocaine)
Do you consume caffeine (i.e. coffee, tea) on a daily basis?
Have you ever been diagnosed with or suspected to have any of the following by a Physician:

Do you have a family history of:

Cardiovascular Disease
Polyps
Cancer

If yes, please specify:

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