OPEN ACCESS COLONOSCOPY PATIENT QUESTIONNAIRE

The Office of Dr. Vivian Asamoah

25230 Kingsland Blvd, Ste 101 Katy, TX 77494
P: (281)-746-9284 F: (877)-327-8082
OPEN ACCESS COLONOSCOPY PATIENT QUESTIONNAIRE
INTRODUCTION
A Colonoscopy is a relatively short and safe procedure. However, as with any medical procedures, complications are possible. To minimize the risk of unexpected events or possible complications, please read carefully and complete the questionnaire below. It is important that you answer all questions as accurately as possible. Answers to questions 9 and 10 will be updated at the time of colonoscopy by your physician. At that time, you will also be examined and you will have the opportunity to discuss any important issues with your physician. Should you have additional questions prior to scheduling, we recommend scheduling an appointment.

Please be advised that fulfilling your request may not always be possible. It is up to the discretion of the provider to determine whether you qualify for the open access program. If you do not qualify, you will be asked to schedule an appointment in the office to establish care before scheduling your colonoscopy.

Once you have completed the questionnaire, our office will reach out to you within 7-10 business days to schedule your colonoscopy.
PATIENT DEMOGRAPHIC INFORMATION
Name:*
Date of Birth*

MonthDayYear
Date
Age:
Sex:*
Marital Status:
Address*

Address

Street Address Line 2

CityState

Zip Code
DOB:
Social Security Number (last four):
Primary Phone:*
Cell Phone:*
Email address:*
example@example.com
The best way to contact you is by: (Phone or email?)
My preferred time frame for the procedure is:

As soon as possiblewithin a monthwithin few monthsI have no preferenceOther:
PATIENT HEALTH INFORMATION
Weight:*
Height:*
GENERAL HISTORY
(Please circle the correct answer (YES or NO) and check all boxes with positive answers to the respective question)
1. Are you allergic to any medications ?

YesNo
If YES, list all medications, including strength and dosing :
2. Do you currently smoke?

YesNo
Do you Drink Alcohol?

YesNo
Have you ever been diagnosed with colorectal cancer?

YesNo
Did you have any colonoscopies performed after the diagnosis of colon cancer?

YesType option 2
If YES, when was your last colonoscopy
Do You have any family history (first degree) of colon cancer?

YesNo
Do You have any family history (first degree) of Colon Polyps?

YesNo
If YES, check all the relatives with polyps and/or cancer (First degree relatives)

MotherFatherBrotherSisterChild
Explain (include age of diagnosis):
PREVIOUS HISTORY OF COLONOSCOPIES AND ABDOMINAL DISEASES
Have you ever had a full colonoscopy with sedation?*

YesNo
If YES, did you have any complications including:

abdominal painfevernausea / vomitingbowel perforationabdominal gas / bloatingrectal bleeding after the procedureOther
If YES, How many colonoscopies?
If YES, did you have any polyps removed?

YesNo
If YES, When was your last colonoscopy?
Additional comments:
Have you ever been diagnosed and treated for any cancer of an abdominal organ (including prostate, ovary, uterus, liver, gallbladder, pancreas, small bowel, stomach, and abdominal lymphoma) ?

YesNo
If YES, Which organ(s) was involved?
8. Have you had any of the abdominal surgeries listed below:

❑ Cholecystectomy (removal of the gallbladder)❑ Appendectomy❑ Hysterectomy (removal of the uterus)❑ Hernia repair❑ C-section❑ Other not listed (please describe briefly)
MEDICATIONS YOU CURRENTLY TAKE AND PAST MEDICAL HISTORY
List the names, dosage, and frequencies of all the medication you take on a regular basis or have taken within the last 2 weeks (including supplements and over the counter medications)
Specifically, within the last week did you at least once take any of the following blood thinners:

Aspirin, Ibuprofen, Advil, Naprosyn, Voltaren, Aleve or similar anti-inflammatory medicationsCoumadin (Warfarin)HeparinLovenox (Enoxaparin)Plavix (Clopidogrel)Ticlid (Ticlopidine)Pradaxa (Dabigatran)Other
Have you ever been treated for any of the following disorders?
Asthma

YesNo
Diabetes Stroke

YesNo
Heart Attack

YesNo
Emphysema

YesNo
Sleep Apnea

YesNo
Loss of consciousness

YesNo
Irregular Heartbeat

YesNo
Abnormalities in blood clotting

YesNo
Crohn's Disease or Ulcerative Colitis

YesNo
Seizures

YesNo
Hypertension

YesNo
PAST HISTORY OF HEART DISEASES
Have you ever had a heart or lung surgery?

YesNo
Do you have a pacemaker?

YesNo
Do you have an implanted defibrillator?

YesNo
Do you have an artificial heart valve?

YesNo
Have you ever had endocarditis?

YesNo
Have you ever had any complications with anesthesia?

YesNo
If yes, explain.
Please, carefully review all your answers above. If you are uncertain about some of the answers, leave the space blank or place a question mark. You will have the opportunity to clarify these issues later, during a short interview with a member of our staff.
PATIENT STATEMENT
I have reviewed the above Pre-Colonoscopy Patient Questionnaire, and I have answered all the questions to the best of my knowledge. I understand that incomplete or false information may result in unexpected complications related to the colonoscopy procedure itself, or to the anesthesia. These complications, which may happen even with your excellent health, may include abdominal pain and bloating, bleeding, bowel perforation, and reaction to medications. I also understand and accept the fact that my colonoscopy may not be completed due to inadequate preparation of the colon, my reactions to the medications used for conscious sedation, or excessive risk for complications as decided by the performing physician before or during the procedure, in which I may need to reschedule at a different time. I understand that submitting this form does not guarantee that my procedure will be scheduled and the office may advise that I schedule an appointment in the office.
Patient's Signature*

Clear
Print Name*
Date*

MonthDayYear
Date
Should be Empty:

P: (281)-746-9284 F: (877)-327-8082

OPEN ACCESS COLONOSCOPY PATIENT QUESTIONNAIRE

INTRODUCTION

PATIENT DEMOGRAPHIC INFORMATION

PATIENT HEALTH INFORMATION

GENERAL HISTORY

PREVIOUS HISTORY OF COLONOSCOPIES AND ABDOMINAL DISEASES

MEDICATIONS YOU CURRENTLY TAKE AND PAST MEDICAL HISTORY

PAST HISTORY OF HEART DISEASES

PATIENT STATEMENT