Home > Medical History Questionnaire > Pre-Surgical Assessment and Testing > Patient & Visitor Info > Endoscopy Medical History Questionnaire Endoscopy Medical History Questionnaire Please answer as many questions as possible. Please note: this form is multiple pages, please click the Submit button on the final page to ensure this reaches our team. You will see a Thank You page when the form is completed. Patient Information Patient’s Name Last:* First:* Middle:* Date of Birth Month, Day, Year (xx/xx/xxxx):* Patient's Contact Information Home number or primary phone number with area code:* Mobile number with area code: Work number with area code: Patient’s Emergency Contact Information Name:* Relationship to you: * Home number or primary phone number with area code:* Mobile number with area code: Patient’s Doctor Information Date of Surgery (xx/xx/xxxx) Surgeon’s Name:* What surgical procedure (operation) are you having? Please describe below.* Family Physician’s Name: Phone number with area code: May we send reports to your family physician? No Yes Please contact your family doctor to see if you need to be seen before you operation. Are you under the care of a heart, lung or kidney doctor? If yes, please tell us his or her: Name: Phone number with area code: Please notify them of your surgery in case they need to see you before your operation.
