Test

—Please choose an option—Tousif Pasha, MDMickey Weisz, MDAyaaz Ismail, MDHomer Iraninezhad, DOSelect your physician

—Please choose an option—American Indian/Native AlaskanAsianBlack/African AmericanNative Hawaiian/Pacific IslanderWhiteHispanic/LatinoOther

First name - last name and relationship

Emergency contact phone

—Please choose an option—HMOPPO

Pharmacy - Major Cross Streets - Zip Code

Screening for colon cancerHistory of colon polyps/cancerFamily history of polyps/cancerAbdominal PainChest painDiarrheaConstipationChange in bowel habitsHeartburnDifficulty swallowingNauseaVomitingPoor appetiteRectal BleedBlood in stoolWeight lossAnemiaHepatitis CAbnormal liver testOther

NonePenicillinSulfa drugsIodine ContrastCiproErythromycinOther

Please type allergic reactions and other medication allergies?

NoneBlood thinners (Coumadin (warfarin), Pradaxa, Xarelto, Eliquis)LisinoprilAmlodipineMetoprololBystolicBenicarMetforminGlipizideInsulin (e.g lantus)Levothyroxine (e.g. synthroid)Statins (Simvastatin, Crestor, Vytorin)Aspirin 81mg , Aspirin 325mg

Please type names of other medications you take

—Please choose an option—Never smokedEx-smokerCurrent smokerSmoking history

—Please choose an option—Social useModerate useHeavy useQuit, heavy use in pastQuit, moderate use in pastQuit, moderate use in pastDo not drinkAlcohol history

—Please choose an option—YesNoDid you get the Flu Vaccination?

Height Ft' Inches" (5'9")

(lbs)

Heart Disease, Heart attack (MI), Atrial fibrillationPacemaker, AICD-defibrillatorHeart failureHypertensionDiabetesCOPD/Emphysema/Asthma/Lung diseaseLow Thyroid (hypothyroidism)High cholesterolAnxietyDepressionBipolarChronic kidney diseaseKidney DialysisStroke or TIAParkinson's diseaseSeizure disorderDifficulty with anesthesiaEndocarditis (heart valve infection)Sleep apneaMigraine headachesGall stonesPancreatitisPeptic ulcer disease (bleeding)

No major surgeriesCardiac pacemaker or AICDCoronary heart bypass surgeryHeart valve surgeryAbdominal aortic aneurysm surgeryGastric bypassGastric sleeveGastric lapbandGall bladder removedHiatal hernia repairInguinal hernia repairKnee or Hip replacementSplenectomyBladder repair

Colon cancerUterine cancerLiver cancerStomach cancerEsophageal cancerBarrett's esophagusCrohn's or Ulcerative ColitisCeliac disease

FeversHeadache or Blurred visionSore throat, hoarsenessCoughWheezingBloody sputumShortness of breathChest painPalpitationsSwelling of legsMuscle ache or Joint pain or joint swellingDifficulty urinatingSkin rash or ItchingBleeding tendency or Easy bruisingWeight loss or loss of appetiteDepressed or sadAnxious or nervous