The Oregon Clinic, West Hills Gastroenterology Colonoscopy Constipation Preparation Instructions (Gatorade/miralax) Page 13
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14Procedure
Medical History Form
WEST HILLS GASTROENTEROLOGY
PLEASE PRINT USING BLACK INK
Name ________________________________________________________________ Today’s Date _____________________
LAST
FIRST
MIDDLE
Soc. Sec. # _________________________________ Date of Birth _______________________ Age ________ Sex ________
Primary Care Doctor/Nurse: _____________________________ Referring Provider
: ___________________
(if different from PCP)
Have you ever been diagnosed with any of the following:
q High Blood Pressure
q Cancer
q Gout
q Heart Disease
q Migraines
q Glaucoma
q Rheumatic Fever
q Elevated cholesterol
q Blood Transfusion
q Stroke
q Fibromyalgia
q Seizure / Epilepsy
q Asthma
q Under / over - active thyroid
q Sleep Apnea
q Arthritis
q Diabetes
q COPD / Emphysema
Have you ever
had a Colonoscopy? q Yes q No If yes, where? ___________________________________ when? _______________
Sedation History
Have you previously undergone:
IV Conscious Sedation (such as for a “GI scope procedure”)?
q No
q Yes
Were there complications? (Please list) _____________________________________________________________
General Anesthesia?
q No
q Yes
Were there complications? (Please list) _____________________________________________________________
Current Medications
What Pharmacy do you currently use?______________________________________________________________________
Please bring a detailed list of medications with doses OR medication bottles OR fill out the table below. (Include over
the counter medications and supplements).
Reason
Medication
Dose / Frequency
•
Do you take Coumadin (warfarin) or other blood thinners?
q Yes
q No
•
Are you taking any supplements that contain Ginkgo Biloba?
q Yes
q No
ALLERGIES to Medications
Medication
Reaction
Do you have an ALLERGY to:
Eggs? q Yes q No
Soy? q Yes q No
Lidocaine? q Yes q No
Continued on next page
toc PMHF 03/11
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