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Online Colonoscopy Scheduling

Your family physician is referring you to us for further evaluation. What kind of problems are you having?*
Are you being referred for a regular screening colonoscopy?*
If yes, please check a preferred physician or day of the week from the options below:*

















Today’s Date:*
Referring Physician and Practice:


PATIENT REGISTRATION FORM

Patient Name First Name:*  Last Name:*
Marital Status:*



Date of Birth:*
Age:*
Phone Number:*
Address:*
City:*  State:*   ZIP:*

Emergency Contact (not living with you):*
Phone Number:*
Relationship:*

Patient Employer:
Employer Address:
City:  State:   ZIP:



INSURANCE INFORMATION

Primary Insurance:*
ID Number:*
Group Number:
Phone Number:*
Insurance Address:
City:  State:   ZIP:
Effective Date:*
Name on Card:*
Secondary Insurance:
ID Number:
Group Number:
Phone Number:
Insurance Address:
City:  State:   ZIP:
Effective Date:
Name on Card:


PATIENT MEDICAL HISTORY INFORMATION

Have you ever had a colonoscopy before?*
Date of previous colonoscopy:
Results of previous colonoscopy(ies) if applicable
Normal:*
Colon Cancer:*
Colon Polyps :*
Do you take Coumadin/Warfarin or other blood thinners?*
Do you take Plavix/Clopidogrel?*
Do you take NSAID’s on a regular basis (ibuprofen or Naproxen):*
Do you take aspirin or aspirin containing products daily?*
Do you have an implantable pacemaker and/or defibrillator?*
Do you have an artificial heart valve?*
Do you require antibiotics before surgical/dental procedures?*
If yes, why?
Are you diabetic?*
If you are diabetic, do you take insulin?*
Please list insulin type(s) and does(s) taken daily. If you do not take insulin respond with "none".*
Have You Had Any of the Following?
High Blood Pressure?*
Comments:
Low Blood Pressure?*
Comments:
Stroke:*
Comments:
Heart Attack/Heart Disease/Murmur:*
Comments:
Angina/Chest Pain:*
Comments:
Allergies/Sinus Problems:*
Comments:
Asthma:*
Comments:
Emphysema/COPD:*
Comments:
Lung Disease, TB:*
Comments:
Arthritis:*
Comments:
Diabetes/Hypoglycemia:*
Comments:
Seizures:*
Comments:
Fainting:*
Comments:
Rheumatic Fever:*
Comments:
Liver Disease (Cirrhosis, Cysts, etc.):*
Comments:
Hepatitis:*
Comments:
Mono:*
Comments:
Jaundice:*
Comments:
Gallbladder Problems (Stones):*
Comments:
Stomach Problems (Ulcerative Colitis, IBD, Chrons Disease, indigestion, reflux, hiatal hernia):*
Comments:
Colon Problems (polyps, Ulcerative Colitis, diarrhea, diverticulitis, spastic colon):*
Comments:
Depression, Anxiety, Stress:*
Comments:
Neurological Disorders:*
Comments:
Cancer (specific type):*
Comments:
Glaucoma/Cataracts:*
Comments:
Anemia:*
Comments:
Rectal Bleeding:*
Comments:
Vomiting Blood:*
Comments:
Motion Sickness:*
Comments:
Blood Transfusions:*
Comments:
Bleeding Problems:*
Comments:
Other:*
Comments:
Please List All/Any Allergies to Medicines and Reaction. If none, please respond with "none".*
Do you have an allergy to latex? *
Current Symptoms: (Please check all that apply):*






List other Symptoms:
Family Medical History
Parents, siblings, children:
Stomach:*
Relation:

Site:
Colon:*
Relation:

Site:
Liver:*
Relation:

Site:
Gallblader:*
Relation:

Site:
Cancer:*
Relation:

Site:

If you are having a colonoscopy, because you will be sedated, you will not be able to drive after your procedure. You must arrange for a responsible adult (over 18) who can drive you to the center and stay until you are discharged. Additionally, a responsible person shoud stay with you for no less than 24 hours after your procedure.

RISKS OF COLONOSCOPY

While colonoscopy is an outpatient procedure, it is an endoscopic procedure performed in an outpatient surgical setting and certain risks are inherent to the procedure. You will be able to discuss the risks below with the physician on the day of your colonoscopy. A detailed informed consent form will be discussed with you on this day and you will be required to sign this form to undergo the colonoscopy.

Risks of Colonoscopy: (most common risks are listed; other rare risks/complications may not be listed below)


1. Abdominal pain
2. Bleeding
3. Infection
4. Adverse reaction to sedation such as: allergic reaction (systemic or local), respiratory depression, low heart rate or low blood pressure
5. Perforation (tearing of the colon) necessitating surgery to repair.
6. Inpatient hospital admission due to any of the above reasons.