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Matthew Eidem, MD
Office Hours Mon-Fri 8:30am - 4:30pm

Office Phone Number: 972-867-0019
Office Fax Number: 972-867-7785

Name *

Phone Number *

Email *

Date of Birth *

Gender

Height in Inches

Weight in Pounds (lbs)

Name of Primary Care Doctor

Pharmacy Name

Pharmacy Phone Number

Insurance Carrier

Member ID#

Group ID#

Insured Date of Birth

Name of Insured

Relationship

Insurance Customer Service Phone Number

Do you have a secondary health insurance?

Yes No

Have you had Colonoscopy in the past?

Yes No

If so, when and where was it performed?

If you have had a colonoscopy in past, what were the results of the prior exam

Do you have a family history of Colon Cancer or Colon Polyps?

Colon Cancer Colon Polyps None

If you have a family history of Colon Cancer or Colon Polyps, which relatives were diagnosed?

Do you have a history of cancer? If so, what type and when was it diagnosed?”

Are you allergic to any medications?

Yes No

If you have any drug allergies please list them below? (Please include any latex or tape allergies)

Do you take any Aspirin or Blood thinner medication?

Name of the physician who prescribed the medication

Please list all medications below including any over-the-counter medications, natural medications, vitamins and supplements

Are you currently experiencing or recently experienced any symtoms such as weight loss, etc.

Yes No

Are you currently anemic? (low blood count)

Yes No

Do you have a pacemaker or implanted defibrillator device?

Yes No

Have you ever been diagnosed with an Inflammatory Bowel Disease such as Crohn's Disease or Ulcerative Colitis?

Yes No

Have you ever been diagnosed with any of the medical conditions listed below? (please check all that apply):