Name:

Procedure:  Colonoscopy EDG Both Other

Reason For Procedure ( if routine screening, skip to Medications: 

Any blood in stool or vomitus?:

Any other symptom?:

Does anything make the problem better?:

How long have you had this problem?:

Medications:

Allergies: 

Height:  Weight:

Any loose teeth?:          False teeth?:     

Damaged teeth:?

Do you have: (Please check all that apply)

Glaucoma                Lung Disease                  Asthma

Bronchitis                Emphysema                    Sinusitis

Heart Disease          High Blood Pressure       Heart Attack

Congestive Heart Failure            Seizures        Stroke

Chest Pain                                       HIV        Hepatitis

Kidney Disease                         Diabetes        Thyroid Problems

Head, Neck, or Back Injury      Anemia

Previous Operations:

Anesthesia Problems:

Family History of Cancer:   

Relation to you:

Type of cancer: