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History Form Name Age Sex Mailing address City State Zip/Postal code Country Phone Fax E-mail address Query details Total no.of motions in a day Consistency of stool Passage of blood Yes No Passage of mucus Yes No Urgency to go to toilet Yes No Loss of energy Yes No Loss of weight Yes No Pain in abdomen Yes No Any other complaint Present medication Investigation(Sigmoidoscopy/Colonoscopy /Histopathology/Barium Enema) Present Food