Please complete the patient history form and bring it with you to your appointment.  Thank you.  

Colon & Rectal Disease Center
Mahendra K. Matta, M.D.  

(please print)
Name: ____________________________________ Date: ____________

Date of Birth: __________ Age: ______ Heigth: ______ Weigth: ________

Referred By: ____________________ Your Occupation: ______________

What is the reason for your visit? (please circle the symtoms or problems you are
                                                           experiencing)

Abdominal pain                              Blood in Stool         
Constipation                                  Nausea        
Indigestion                                     Rectal Bleeding (See below)      
Rectal Swelling                              Weight Loss          
Rectal Pain                                    Rectal Burning
Change In Stool Size                      Hemorrhoids                        
Inability to hold stool/gass               Rectal Seepage      
Change in Bowel Habit                    Bloating
Diarrhea                                         Gas 
Vomiting                                         Itching

Is the blood mixed in the stool?   Yes    No  *Is the blood bright red or dark in color?   Bright       Dark

How many bowel movements do you have per day? ____________

Other symptoms not listed above: _________________________________

How long have you had this problem? _____Days ______ Mnths _____YRS

Have you seen another physician for this problem?   Yes      No
Dr. __________________________

Have you lost or gained weight in the past 3 to 6 months?   Yes       No
    +     -     ________ pounds

Hospitalizations:(If you have been in the hospital, state the year and illness or operations you have had.)
____________________________________________________________________

____________________________________________________________________

Past Medical History: Have you ever had the following: (circle all that apply)

AIDS                Breast Lump                 Hepatitis                  Pneumonia
Alcoholism        Bronchitis                     Hernia                     Prostate Problem
Anemia             Bulimia                        Herpes                     Psychiatric Care
Anorexia           Cancer                         High Cholosteral       Stroke
Appendicitis      Chemical Dependency   HIV Positive             Thyroid Problem
Arthritis             Diabetes                      Kidney Disease        Tuberculosis
Asthma             Emphysema                 Liver Disease           Ulcers
Bleeding Disorder                                  Heart Disease

Social History:  (circle which substances you use and describe how you use)

Tobacco       Y      N       Packs per day ___________ For _________ years

Alcohol         Y      N      Drinks per day ________________________

Caffeine         Y     N       Cups per day _________________________

Other Drugs   Y     N       Type: ________________________________

Family History: (circle if any of your blood relatives had any of the following and circle relationship)

Colon cancer:   _________________  mother     father     sibling     grandparent     aunt/uncl

Colon polyps:   _________________  mother     father     sibling     grandparent     aunt/uncl

Other Cancer:   _________________  mother     father     sibling     grandparent     aunt/uncl

Current Medications: (list all current medications and dosage)
________________________________________________________________

________________________________________________________________

________________________________________________________________

Do you take any blood thinning medications?    Yes    No

Do you take?  (circle all that apply)    Coumadin     Plavix     Ticlid     other ______________

Do you take asparin daily?   Yes        No     __________mg.

Are you allegic to any medications?   Yes (list)        No    ________________________________________________________

________________________________________________________


---------------------------------------office use only-----------------------------------------------

Reviewed by: __________________________________