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3Assessment Form
3. Do you have any drug, food or latex allergies?
☐ YES
☐ NO
If yes, please complete the following:
Name of Drug
Type of Reaction
Name of Food
Type of Reaction
4. Are you on COUMADIN (WARFARIN) or any blood thinners?
☐ YES
☐ NO
5. Have you had a prior colonoscopy or endoscopy?
☐ YES
☐ NO
If NO, please proceed to question #6.
If YES;
Date of Procedure: _________________________
Location of Procedure: ______________________
Results: _________________________________________________
6. Please list all operations during which you received general or other type of anesthetic/sedation?
Name of Operation: ____________________________
Year: ________
Name of Operation: ____________________________
Year: ________
Name of Operation: ____________________________
Year: ________
7. Have you or any member of your family had a reaction to local/general anesthetic/sedation? (not including
nausea or vomiting)?
☐ YES
☐ NO
If Yes, please provide details: ____________________________
8. Do you consume alcohol on a daily basis? ☐ YES, number of years ____
☐ NO
Number of drinks per day ______
9. Do you smoke or use nicotine? ☐ YES, number of years ____
☐ NO
10. Do you use recreational drugs? (I.e. marijuana, cocaine) ☐ YES
☐ NO
If yes, please provide details: __________________________________
11. Do you consume caffeine (i.e. coffee, tea) on a daily basis? ☐ YES, number of years____ ☐ NO
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