Questionnaire Before Your Test

Name: DOB:                         Age:         Gender:   M   F

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?



Who is driving you home today?

Which laxative did you take?


BiPeglyte (2 litres) ___


Peglyte (4 litres) ___

Phone number:


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