Colonoscopy Form

First Name

Middle Initial

Last Name

Date of Birth

Gender

Social Security Number

Race

Street Address

City

State

Zip Code

Telephone primary

Telephone secondary

Emergency Contact

First Name

Last Name

Phone Number

Pharmacy

Insurance (If yes, please provide details below.)

Yes No

Insurance carrier

Member ID number

Group number

Insured Name

DOB

Relationship

Secondary Insurance:

Upload your insurance card picture in the button below:

Front of card:

Add file

Please upload a file

Back of card:

Add file

Please upload a file

Reason for colonoscopy

Colon Cancer Screening Family History of Colon Cancer Personal History of Polyps Other

When was your last colonoscopy (if applicable)

Findings of your last colonoscopy (if applicable)

Personal history of colon polyps

Yes No

Family history of colon cancer

Yes No

If yes, who?

Family history of colon polyps

Yes No

If yes, who?

Primary care physician

Referring physician

Do you see a heart specialist (cardiologist)

Yes No

Medical Problems

Past Surgeries

Allergies

Medications

Do you take any blood thinners?

Yes No

Do you have sleep apnea?

Yes No

Do you use oxygen?

Yes No

Do you have an ICD (Implantable Cardioverter Defibrillator)?

Yes No

Did you have a heart attack or stroke in the last 6 months?

Yes No

Are you able to move your neck side to side and up and down?

Yes No

Are you on dialysis?

Yes No

Do you have a bleeding disorder?

Yes No

Any abdominal/bowel surgeries in the last 3 months?

Yes No

Any problems with anesthesia?

Yes No

Height

Weight

BMI

Do you have chronic abdominal pain?

Yes No

Do you have heartburn?

Yes No

Do you have trouble swallowing?

Yes No

Do you see blood in your stool or in the toilet?

Yes No

Do you have constipation or diarrhea?

Yes No

You must have a driver for all testing-family member/friend/neighbor
-NOTRANSPORTATION SERVICES.

Social History

Do you smoke? How much?

Do you drink? How much?

Hx of Drug Abuse?

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