LAST NAME, FIRST NAME ___________________________________
Date of Birth: ____________
Colon & Rectal Surgery Patient Registration Form
Last Name:
Address:
City:
Male
Female
Social Security Number:
First Name:
State:
Age:
Middle:
Zip:
Date of Birth:
Your Contact Information
Home Phone
Cell Phone
Work Phone
Fax Number
Email
Preferred method of contact
Marital status (circle one): Single Married Divorced
Widowed Separated Partnered Other
Employment Status (circle one): Full-time Part-time
Self-employed Retired Student Unemployed/Disability
Job title:
Responsible Party (party responsible for payment): Self Spouse Other
Last Name:
First Name:
Address:
Phone:
City:
State:
Zip:
Middle:
Primary Insurance:
Name of Plan:
Group #
ID#
Insured Party: Self Spouse Other
Secondary Insurance
Name of Plan:
Group #
ID#
Insured Party: Self Spouse Other
In case of emergency, who should we contact?
Name
Relationship to you
Phone #
Email
Which doctor sent you to us?
Name (first last)
Specialty
Address
City, State
Phone #
Who is your primary care physician?
Name (first last)
Specialty
Address
City, State
Phone #
Any other physicians we should contact?
Name (first last)
Specialty
Address
City, State
Phone #
What is your preferred pharmacy?
Name
4-digit code
Address (or Street)
City, State
Phone #
MRN: _________________
none
I’m self-referred
none
Name (first last)
Specialty
Address
City, State
Phone #
Today’s Date: ___________
LAST NAME, FIRST NAME ___________________________________
Date of Birth: ____________
Colon & Rectal Surgery Patient Health Questionnaire (pg 1 of 3)
What brings you in today?
Medications (including over-the-counter):
Name
Dose
Frequency
Medication Allergies (please describe reaction):
List any Major Medical Problems:
Date Started
no known drug allergies
none
Past Surgical History (list month and year):
none
Family History:
Father:
Alive
Mother: Alive
none
Deceased; if so, cause:______________________
Deceased; if so, cause:______________________
Family member relationship to you:
Any family with colon or rectal cancer?
no
yes
____________________________________________
Any family with colon or rectal polyps?
no
yes
____________________________________________
Any family with Crohn’s or colitis?
no
yes
____________________________________________
Any family history of uterine cancer?
no
yes
____________________________________________
Social History:
Alcohol Use:
no
yes ____# of drinks/day
Smoking History:
no
yes ____# packs/day
If you have quit, when?____________
Recreational Drugs: no
yes, name of drug(s) __________________________________
Date of last colonoscopy: ______________
none
Findings: ____________________________________
Name of doctor who did your last colonoscopy __________________________________________
MRN: _________________
Today’s Date: ___________
LAST NAME, FIRST NAME ___________________________________
Date of Birth: ____________
Colon & Rectal Surgery Patient Health Questionnaire (pg 2 of 3)
Review of Systems: Do you have or have you had any problems with the following systems? If so, please describe.
(please answer to the best of your ability):
General (fever, poor appetite or weight loss)
none
Breast (nipple discharge, breast pain, abnormal mammogram, breast enlargement
none
Cardiac (history of heart attack, any heart procedures, chest pain, palpitations, syncope, peripheral edema)
Respiratory (cough, shortness of breath, wheezing)
none
none
Vascular (any varicose veins, leg swelling, pain in legs with walking, resting leg pain, pain at night in legs)
Genitals (any issues with your vagina/penis, any genital warts, any anal warts)?
none
none
GU (painful urination, blood in urine, any discharge, change in urinary frequency, urinary hesitancy, nocturia, incontinence,
erectile dysfunction)
none
Skin (any new skin lesions, changes in mole(s), rash, any history of skin cancer)
Neurologic (paralysis, paresthesias, seizures, frequent headaches)
none
none
Psychiatric (depression, memory loss, suicidal ideation, hallucinations, paranoia, confusion)
Have you had any trouble with abnormal bruising or bleeding? Any enlarged lymph nodes?
Do you have any back pain, sciatica or arthritis?
Do you have any gastrointestinal issues?
Any anal or rectal bleeding?
Any change in bowel habits?
Diarrhea?
no
Constipation?
no
none
none
yes
yes
yes
no
yes
Anal lump?
no
yes
no
Abdominal pain?
no
none
yes
Anal pain?
Anal itching?
no
none
yes
no
yes
MRN: _________________
Today’s Date: ___________
LAST NAME, FIRST NAME ___________________________________
Date of Birth: ____________
Colon & Rectal Surgery Patient Health Questionnaire (pg 3 of 3)
How often do you have BMs? _______________ Do you have to strain to have a bowel movement? no
yes
Do you take anything to help have a BM? ___________________________________________________________
Have you ever been tested for HIV?
no
yes, Date of last test _________
If you were tested, what were the results?
negative
positive
If positive: Name of HIV doctor ______________________,
Date of latest labs drawn __________ CD4 count? __________
Viral load? _________
Have you had human papilloma virus (anal warts)? no
yes Any history of dysplasia? no
yes
Other sexually transmitted diseases? no
yes
If yes, which ones and when? ____________________________________________________________________
Do you have any fecal incontinence? no
yes
If YES, complete this section. If NO, then move to the next section below.
Are you incontinent to solid stool, liquid stool or gas? (Circle all that apply)
Which symptoms best describe you?
□ Bowel accidents because I am unable to make it to the bathroom in time
□ Bowel accidents while asleep/unaware
□ Frequent, loose, watery stools
□ Abdominal pain
How long have you had these symptoms? ___________________________________________________________
Approximately how often do you have bowel accidents (daily, weekly, monthly)? ____________________________
Amount per episode (for example do you wear a pad, how many times do you have to change it)? ______________
What behavior modifications have you tried?_________________________________________________________
(i.e., lifestyle changes, fiber, diet changes, pelvic floor muscle training/biofeedback)
Have you tried medications to help your symptoms?
□ Yes □ No
If yes, then check the medications you have tried:
□ Imodium®
□ Lomotil ®
□ Imotil®
□ Diphenoxylate
□ Loperamide □ Other _______________
Did these medications help your symptoms? _______________________
If you have stopped taking your medications, then explain why.
□ Did not help
□ Side effects
□ Too expensive
Describe the side effects (if any) ___________________________________________________________
Female patients: please provide information on your obstetric/gynecologic history:
Total # Preganancies ___ # Living Children ___ # Vaginal Births: ___ # C-sections: ___ # Miscarriages: ___
Any tears? no
yes
Have you had an episiotomy? no
yes Other complications?_____________
When was your last menstrual period? _______ Have you had a hysterectomy? _______
MRN: _________________
Today’s Date: ___________