Questionnaire Before Your Test
| Name: | DOB: Age: Gender: M F |
| Address: |
|
| Healthcard #: | Preferred Phone #: |
| Marital Status: Married Single Common-law Widowed Divorced | Occupation: |
| Alcohol: Y N If yes, average daily amount: | |
| Tobacco: Y N If yes, average daily amount: | |
| Marijuana/THC: Y N If yes, average daily amount: | |
Please tell us about your health:
| Y | N | Please Specify: | |
| Do you have FREQUENT bowel problems? | |||
| Has your bowel function changed? | |||
| Have you ever passed blood? | |||
| Do you have serious abdominal pain? | |||
| Recent weight loss? | If YES, then was the weight loss voluntary? YES NO | ||
| Females: Any chance of pregnancy? |
Family History of Colorectal Cancer and/or Polyps (Circle answer): YES NO
| If yes, who in your family? (list family members below, e.g. mother, uncle, etc.) | |
| Colon/Bowel Cancer | |
| Colonic Polyps |
Please list your MEDICAL CONDITIONS and past SURGERIES:
Please list your MEDICATIONS (Name, Dosage, Frequency):
Drug Allergies?
EMERGENCY CONTACT:
PHONE:
Who is driving you home today?
Which laxative did you take?
Name:
BiPeglyte (2 litres) ___
Relationship:
Peglyte (4 litres) ___
Phone number:
Other: