Patient Form – 3

Constipation
Hemorrhoids
Rectal pain
Colon polyps
Other

Diarrhea
Excessive gas
Rectal bleeding
Colon cancer

Pain with bowel movement
Black stools
Rectal itching
Family history of colon cancer

Yellow eyes/skin (Jaundice)

Cirrhosis

Hepatitis

Gallstones

Gallbladder surgery

Pancreatitis

Fevers

Night sweats

Fatigue

Rashes

Sores

Skin cancer

Thyroid problems

Abnormal tolerance to hot or cold

Diabetes

Yellowing of eyes

Discharge

Other

Frequent nose bleeds

Change in voice

Other

Murmur
Angina
Cardiac stent

Palpations
Congestive heart failure
Cardiac surgery

Heart attack
High blood pressure
Other

Asthma

COPD

Lung cancer

Burning with urination

Pain with urination

Blood in urine

New joint pain

New back pain

Arthritis

Recent infection