Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Colonoscopy Medical History
Patient Full Name *
Date of Birth
____ / ____ / ________
Reason for Colonoscopy
Current GI Symptoms
Previous Colonoscopy Date
____ / ____ / ________
Polyp or Cancer History
Family Colorectal Cancer History
Current Medications
| Medication | Dose | How often |
|---|---|---|
Anticoagulant Use
Colonoscopy Medical History template from formisoft.com. formisoft.com/intake-templates/colonial-period-medical-history