Intake Form Today's Date Date Format: MM slash DD slash YYYY First Name* First Last Name* Last Phone*Email* Date of Birth* Date Format: MM slash DD slash YYYY Referring PhysicianPhysicians who will need reportReason for VisitReason for today’s visit:Please check any of the following symptoms that you are experiencing:* Change in Bowel Habits Diarrhea Abdominal Pain Abnormal X-ray/CT Scan ER Visit Weight Loss Difficulty Swallowing Heartburn Blood in Stool/Rectal Bleeding Anemia Nausea/Vomiting If ER Visit was checked, what was the diagnosis?Personal HistoryHave you had any of the following? Colon Polyps Cancer Niether If yes please explainFamily HistoryFamily History Colon Polyps Colon Cancer Rectal Cancer Esophageal Cancer Barrett’s Esophagus If checked please describe the relationship to family member and at what age were they diagnosedMedical ConditionsCheck which apply to you Asthma COPD (Emphysema) Sleep Apnea Recent Infection Irregular Heartbeat Pacemaker/Defib Heart Failure Heart Attack HIV Hepatitis B/C Clostridium Difficile Cirrhosis Kidney Disease Diabetes Type 2 Diabetes Type 1 Anxiety/PTSD Please List Surgical History with Approximate DatesSocial History Tobacco Marijuana Alcohol Caffine If checked, explain what, how often, or if you've quitPreferred Pharmacy/ Which LocationPlease list any known allergiesAllergyReaction Please list any medications you are currently takingMedication NameDoseLast Taken
