Patient Questionnaire Form Page 2

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Winter Park Colon & Rectal Specialists, LLC
JACQUELINE L. KAISER, MD
255 N. Lakemont Ave. #100
Winter Park, FL 32792
DATE: ____________________
PATIENT NAME:
DOB:
__________________________________________________
_________________
REASON FOR THIS VISIT
: _____________________________________________________________________________
REFERRED BY
:
Dr.________________________
Patient______________________________
______________
Hospital
Insurance
Internet
CURRENT MEDICATIONS & SUPPLEMENTS
____________________________________________
PLEASE ANSWER THE FOLLOWING REGARDING
YOUR CONDITION:
____________________________________________
Do you have bleeding from the rectum?
Yes
No
____________________________________________
Do you have anal or rectal pain?
Yes
No
____________________________________________
Do you have pain with bowel movements? Yes
No
____________________________________________
Do you have abdominal pain?
Yes
No
____________________________________________
Do you have high blood pressure?
YesNo
____________________________________________
Do you have diabetes?
YesNo
Do you take Aspirin?
Yes  No 
Have you lost weight recently?
Yes No
If yes, how much? ___________
ALLERGIES TO MEDS, LATEX, ADHESIVE, ETC.
Have you traveled out of
____________________________________________
the country recently?
Yes No
If yes, where?_______________________
____________________________________________
____________________________________________
Smoking Status/History
Never Smoked
____________________________________________
Former Smoker
Current some day smoker
Current every day smoker
RECENT HOSPITALIZATIONS
Do you drink alcohol?
Yes
No
REASON
DATE
If yes, how much? ____per day
____per wk
____________________________________________
____________________________________________
FEMALES ONLY
Number of pregnancies:
______________
____________________________________________
# of Vaginal deliveries:
______________
____________________________________________
# of Cesarean sections:
______________

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