The Oregon Clinic, West Hills Gastroenterology Colonoscopy Constipation Preparation Instructions (Gatorade/miralax) Page 14
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14Name: __________________________________________________________________________________________________
Surgeries:
Type of Surgery
Date
Doctor
Where
•
Have you ever been advised to have any surgical operation that has not been done? If yes, please explain:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Family History:
Does anyone in your family have a history of:
Diagnosis
Relation
Age at diagnosis
Colon Polyps
Colon Cancer
Habits:
1) Smoking / Tobacco / Nicotine use:
Have you ever smoked or used tobacco / nicotine products?q Yes
q No
q Currently use:
q Cigarettes _________per day
q Chewing tobacco
q Nicotine patch
For how many years: ___________
q Used in the past: q Cigarettes _________per day
q Chewing tobacco
q Nicotine patch
For how many years: ___________
How long ago did you quit? _________________
2) Alcohol use:
Do you drink alcohol?
q Yes
q No
q Currently use:
How much per week:
q beer _______
q wine _______
q liquor _______
q other _______
Was alcohol ever a problem for you in the past?
q Yes
q No
3) Caffeine use:
Do you drink caffeine-containing products? q Yes
q No
q Current use:
How much per day:
q coffee _______
q tea _______
q cola _______
q other _______
4) Do you have a history of recreational or IV drug use?
q Yes q No
When?________
Ongoing?
q Yes
q No
Patient Signature: _______________________________________________________ Date: __________________________
toc PMHF 03/11
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