Comprehensive Colorectal Surgery Patient History Form

Patient Information

• Full Name: _________________ Date: _________________
• Date of Birth: ______________ Age: __________________
• Primary Care Physician: ______________________________

Chief Complaint

What is the main reason for your visit today?

Colorectal History

Current Symptoms (check all that apply):

• Rectal bleeding
• Change in bowel habits
• Abdominal pain
• Constipation
• Diarrhea
• Incontinence
• Other: _________________

Previous Colorectal Procedures

• Last colonoscopy date: _______________
• Previous colorectal surgeries: _______________
• Family history of colorectal cancer: Yes [ ] No [ ]

Medical History

Past Medical Conditions

• Diabetes
• Hypertension
• Heart disease
• Inflammatory bowel disease
• Diverticulitis
• Other: _________________

Current Medications

Allergies

Medications: _________________ Latex: Yes [ ] No [ ]

Social History

• Tobacco use: Current [ ] Former [ ] Never [ ]
• Alcohol use: Yes [ ] No [ ] Amount: _________

Review of Systems

Gastrointestinal

• Nausea/Vomiting
• Weight loss
• Blood in stool
• Mucus in stool

Constitutional

• Fever
• Fatigue
• Night sweats

Patient Signature: _________________ Date: _________________