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Health Questionnaire
Please select Yes if you have you ever had (or have) the following:
Heart Problems
No
Yes
Pacemaker/heart stent or valve
No
Yes
Infectious disease
No
Yes
High Blood Pressure
No
Yes
Respiratory problems
No
Yes
Prolonged bleeding
No
Yes
Cancer
No
Yes
Thyroid disease
No
Yes
Liver disease
No
Yes
High cholesterol
No
Yes
Diabetes
No
Yes
Anemia
No
Yes
History of Anesthesia (Reaction?):
No
Yes
Sleep Apnea
No
Yes
Drug Allergies
No
Yes
Use of Alcohol
Never
Rarely
Moderate
Daily
Use of Tobacco
Never
Quit
Current
Use of Recreational Drugs
Never
occasionally
Frequently
Colon Cancer
No
Yes
Colon Polyps
No
Yes
Breast, Uterine, Ovarian, or Cervical Cancer
No
Yes
Have you ever had a sigmoidoscopy or colonoscopy?
No
Yes
Have you had any significant change in your bowel habits?
No
Yes
Do you regularly have diarrhea or constipation?
No
Yes
Disclosures
In general, The HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.
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Yes
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Yes
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Yes
O.K. to exchange information with referring doctors and treatment facilities?
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Yes
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