Colorectal Surgery Patient Registration and Health History Form

Patient Information

• Full Name: _________________ Date of Birth: _________
• Social Security Number: _____________ Gender: □ M □ F □ Other
• Address: _________________ City: _______ State: ___ ZIP: _____
• Phone: (Home) _________ (Cell) _________ (Work) _________
• Email: _________________
• Emergency Contact: _____________ Phone: _________
• Primary Care Physician: _____________ Phone: _________

Insurance Information

• Primary Insurance: _________________ ID#: _________
• Secondary Insurance: _________________ ID#: _________

Medical History

Previous Surgeries

1. Surgery: _____________ Date: _________
2. Surgery: _____________ Date: _________

Colorectal Symptoms (check all that apply)

□ Rectal Bleeding □ Change in Bowel Habits □ Abdominal Pain □ Constipation □ Diarrhea □ Weight Loss

Family History of Colorectal Conditions

□ Colorectal Cancer □ Inflammatory Bowel Disease □ Polyps □ Other: _________________

Current Medications

Allergies

□ No Known Drug Allergies □ Yes (Please list): _________________

Social History

• Tobacco Use: □ Never □ Current □ Former
• Alcohol Use: □ Never □ Occasional □ Regular

Consent

I certify that the above information is accurate to the best of my knowledge.

Signature: _________________ Date: _________