Patient Information GENERAL INFORMATION Name * First Name Last Name Sex * M F Email * Mobile Number * Date of Birth * MM DD YYYY Occupation * EMERGENCY CONTACT PERSON Name * Mobile Number * MEDICAL CARE PROVIDERS Who is your main doctor (primary care physician)? * Who are the specialist doctors you see? * MEDICAL HISTORY Main problem that brings you here today * Major medical illnesses / medical conditions * Previous surgeries / operations * Any food or medication ALLERGIES? What kind of allergic reaction? * Current medications (prescription medications, over-the-counter drugs, herbal remedies, vitamins & supplements), include dose and frequency: * Are you on blood thinning medication? (ex. Coumadin, Plavix, Aspirin, etc.)? * Do you take injectable medications like Ozempic? * Do you smoke/chew tobacco, or use Vape products? * How much alcohol do you consume? * What medical conditions run in the family? Any history of cancer? * Do you have family history of colon polyps or colon cancer? * Have you had an Upper endoscopy/ Gastroscopy done? When and what are the findings? * Have you had a Colonoscopy done? When and what are the findings? * Any other health concerns you wish to mention: Have you been sick with COVID-19? Please specify dates below: * Medical Insurance (ie. Company, Health Card, PhilHealth, Senior/PWD, Self-Pay) * Thank you!