COLORECTAL Health History Form

NAME: DATE:_

BIRTHDATE: AGE: PRIMARY CARE DOCTOR:

HEIGHT: WEIGHT: CARDIOLOGIST: GASTRO:

PHARMACY (name, location, phone number):

ALLERGIES NONE Codeine Iodine dye Morphine Propofol Surgical tape Aspirin Demerol Latex Penicillin Sulfa Versed

Other: Any prior difficulties with sedation or (nausea/vomiting, high tolerance, other)? Yes No

REASON FOR YOUR VISIT TO THE OFFICE External Diverticulitis Bowel obstruction Internal hemorrhoids Diarrhea Diverticulosis Vomiting Perianal abscess Abdominal pain Diverticular Ulcerative colitis Cramping/gas Polyps Rectal pain/itch Fissure Bloody stool Colostomy Crohn’s disease Pilonidal cyst Incontinence Ileostomy Irritable Bowel (IBS) Colon Screening Family history of colon polyps/cancer

Other:

Have you had any of the following done to evaluate for the cause of your symptoms? Laboratory tests or blood work imaging (x-rays, ultrasounds, CAT scans, MRIs, barium studies) (upper GI scope/EGD, ERCP, colonoscopy) Emergency room visits Have you ever had a colonoscopy? YES NO Date? _ Who Performed? _Location? _ Have you ever had colorectal surgery? YES NO Have you ever had anorectal surgery? YES NO Who performed the surgery(ies) and when? _ Have you ever had C. Difficile? YES NO MRSA? YES NO

** If possible, we would greatly appreciate it if you could please bring any of these relevant records with you or have them faxed to our office in advance of your visit 412-572-6193.

1 PAST MEDICAL ILLNESSES Gastrointestinal Diarrhea Gallstones Ulcerative colitis Anal fistula Hiatal hernia Pancreatitis Crohn’s disease Stool incontinence Gastritis Irritable bowel (IBS) Colon polyp Constipation Heartburn/GERD Lactose intolerance Rectal bleeding Nausea Diverticulosis Hemorrhoids Hepatitis Celiac disease Diverticulitis Cirrhosis Vomiting

Cardiovascular High High Heart attack Congestive heart failure Atrial fibrillation Rhythm disorder Heart murmur

Pulmonary Sleep apnea Asthma Emphysema Pneumonia Pulmonary Sarcoidosis Lung cancer Pleurisy

Neuropsychiatric Stroke or TIA Depression Eating disorder Seizures Migraines Anxiety Parkinson’s disease Myasthenia gravis Chronic headaches Bipolar disorder Dementia

Endocrine Diabetes nodule Goiter Thyroid cancer Hyperthyroidism Pituitary problem Adrenal problem

Genitourinary Kidney disease Kidney stones Kidney tumors/cysts Bladder cancer Urinary tract Bladder incontinence Prostate hypertrophy Prostate cancer Ovarian cyst(s) Uterine fibroids Abnormal pap smears Cone biopsy/LEEP Ovarian cancer Uterine cancer Cervical cancer Endometriosis

Breast Fibrocystic breast changes Benign breast biopsy Breast cancer Chemo/radiation/surgery

Musculoskeletal Osteoarthritis Rheumatoid Fibromyalgia Chronic back pain Osteoporosis Osteopenia Gout

Eyes, Ears, Nose, and Throat Glaucoma Allergic rhinitis Sinusitis Oral thrush

Dermatologic Eczema Psoriasis Vitiligo Alopecia Raynaud’s syndrome Basal cell skin cancer Squamous cell cancer Melanoma

Hematologic Blood transfusion Blood clot Hemochromatosis

2 Additional Health History: Any other malignant tumors/ not previously mentioned:

Any communicable disease, such as hepatitis, HIV, or sexually transmitted disease?

Any other hospitalizations or medical conditions not previously mentioned:

PREVIOUS AND PROCEDURES Gallbladder Appendix Groin hernia repair Abdomen hernia repair Adhesion surgery Colon resection surgery Anti-reflux surgery Weight loss surgery D & C Uterine ablation C-section Tubal ligation Total hysterectomy Partial hysterectomy Vasectomy Prostate surgery Back surgery Lumpectomy Mastectomy Stent/angioplasty Heart bypass surgery Heart valve surgery Pacemaker Defibrillator Carotid surgery stripping

Any other surgeries not previously mentioned:

IMPLANTS/PROSTHESIS: YES NO YES NO Pins Screws Wires Plates Hearing Aid Ports Pacemaker Cardiac Stents Defibrillator Heart Valve Replaced Lens in Eyes R L Breast Implants Knees Replaced R L Hip Replaced R L

MEDICATIONS Please include all prescription and non-prescription medications (especially anti-inflammatories like Advil, Motrin, and Aspirin), as well as all supplements.

Medication Name Dose and Frequency

3 SOCIAL HISTORY Marital status: Single Married Separated Divorced Widowed Children (ages): Occupation:

Do you have any tattoos? Yes No

Do you currently use Yes No Did you ever use tobacco products? Yes No tobacco? When did you quit? Number of packs per day? How many years?

Do you drink alcohol? Yes No Number of cups per day of caffeinated beverages? How many glasses do you drink per day? How many glasses do you drink per week? Have you ever had a problem with alcohol or drug use?

FAMILY HISTORY Colon polyps Helicobacter pylori Crohn’s disease Hepatitis B Colon cancer Stomach cancer Ulcerative colitis Hepatitis C Uterine cancer Ovarian cancer Celiac disease Hemochromatosis

If yes, list family members (i.e. mother, grandmother, sister, aunt) and age at diagnosis if polyps or cancers:

BOWEL SYMPTOM QUESTIONNAIRE Which symptoms best describe you? Check all that apply. Accidental loss or leakage of stool – sometimes unable to make it to the bathroom in time Bowel accidents while unaware – no warning or while sleeping Frequent loose, watery stools Sudden or strong urge to go to the bathroom Bowel accidents when passing gas No bowel problems (if checked, please discontinue questionnaire)

How long have you had these symptoms?_ Approximately how many bowel incidents do you have per week?_ Have you tried medications to help your symptoms? YES NO If YES, which medications? Kaopectate Imodium Lomotil

On a scale of 0 to 10, with 0 being no symptom relief and 10 being complete symptom relief, how much symptom relief have these medications provide for you? Circle Number: 0 1 2 3 4 5 6 7 8 9 10 NO RELIEF COMPLETE SYMPTOM RELIEF

Behavior Modifications tried? (examples: lifestyle changes, diet changes, fiber, physical )

On a scale of 0 to 10, with 0 being no frustration at all and 10 being extremely frustrated, what is your level of frustration with your bowel control symptoms? Circle a number. 0 1 2 3 4 5 6 7 8 9 10 Not Frustrated Very Frustrated

Are you interested in learning about additional treatment alternatives to bowel medications? YES NO

4 REVIEW OF SYSTEMS General Fatigue Weakness Fever Night sweats

Cardiovascular Chest pain Palpitations Shortness of breath with exertion Ankle swelling/ Varicose

Respiratory Cough Coughing blood Shortness of breath Wheezing

Neurologic Headaches Dizziness Localized numbness Speech difficulty Memory loss

Endocrine Cold intolerance Heat intolerance Excessive Excessive hunger Dry skin Abnormal skin pigment Abnormal body hair Brittle hair

Genitourinary Blood in urine Burning urination Urinary incontinence Frequent urination Frequent urination at night

Males: Slow urinary stream Difficulty initiating urination Penile discharge

Females: Abnormal periods Menopause Vaginal discharge

Breast Lump(s) Pain Nipple discharge Enlargement (males)

Bones/Joints/Muscles Pain Swelling Stiffness

Oropharyngeal Mouth sores Tongue sores Tooth/gum problems

Skin Itching Rash Scaling

Hematology Swollen jaw Bruising Bleeding problems

Patient’s Signature Date

5 SCMG COLORECTAL SURGERY 1050 BOWER HILL ROAD SUITE 208 PITTSBURGH, PA 15243

I authorize Dr. Leigh Nadler and/or Dr. Scott Holekamp to perform medical and surgical procedures on me.

These procedures may include flexible , colonoscopy, , biopsies/polypectomies, of abscesses, infrared coagulation and/or rubber band ligation of hemorrhoids, excision of thrombosed hemorrhoid/anal skin tag. Also including anal and rectal ultrasound, removal of Seton drains, application of silver nitrate, removal of rectal foreign body, fecal disimpaction, and cauterization of anal lesions.

I certify that I have read and fully understand the above form. I further certify that the explanations therein have been made clear to me and that all blanks or statements requiring insertions, completions, or deletions have been filled in.

Date: Patient Signature:

Patient Printed Name:

AS THIS IS A SURGICAL PRACTICE AND LIFE-THREATENING EMERGENCIES BEYOND OUR CONTROL MAY OCCUR, IT IS POSSIBLE THAT YOUR OFFICE APPOINTMENT MAY BE DELAYED OR NEED TO BE RESCHEDULED. WE AOLOGIZE IN ADVANCE FOR ANY INCONVENIENCE THAT THIS UNLIKELY AND UNFORSEEN EVENT MAY CAUSE.

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