Zazen Surgery Center Pre Procedure Form - Direct Access Colonoscopy

Surgery Center

Direct Access Pre-Scheduling Form
Patient Name
Date of Birth
Mailing Address
Email Address
Phone Number
Height (Ft./In)
Weight (Lbs.)
Allergies to Medications

NKDAOther
Procedure

COLONOSCOPY
Diagnosis

ScreeningFamily History of PolypsFamily History of Colon CancerHistory of Colon CancerHistory of PolypsOther
Reasons for the Procedure?
For how long have you been experiencing symptoms?
Previous Surgical History
Previous Medical History
List all medications currently taking, including vitamins/supplements
Please list contact information for who will be picking you up from the facility.
Contact Person Phone Number
Can we discuss your results with them?

YesNo
Previous Anesthesia Complications

NOYES
Any family hx of anesthesia complications

YESNO
Do you partake in any of the following?

Drink AlcoholTobaccoRecreational Drugs
Do you have any metal in your body? (i.e. surgical pins, surgical clips, screws)

YesNo
Dental Status

Loose or Chipped TeethCapsPartial PlateDenturesBridgeVeneers
Cardiovascular History

HypertensionCongestive Heart failMVP / MurmurCABGMyocardial InfarctionStent PlacementsPacemakerDysrhythmiaAngioplastyHigh Cholesterol
Cardiologist's Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Respiratory

Congestive Heart FailureSinus DrainageShortness of BreathAsthmaTBChronic CoughSleep ApneaHome O2 nasal canulaCPAPBiPAP
Gastrointestinal/Hepatic

Esophageal StrictureDiverticulitisUlcersCirrhosisPolypsHiatal HerniaHepatitisIrritable Bowel SyndromeUlcerative ColitisHemorrhoidsCrohn's DiseaseGERD
Neurologic

SeizuresStrokeNeuromuscular DiseaseWeakness
Endocrine

NIDDM/IDDMThyroidSteroid UseHypoglycemiaDiabeticInsulin Pump
Musculoskeletal

ArthritisOsteoporosisNeck or Back ProblemsTMJ
Hematologic

Clotting problemsNSAIDS use (Ibuprophen)Anticoagulant use (i.e. Lasix, Asprin)Blood DisordersAnemiaHIV
Renal

Renal InsufficiencyKidney Stones
Dermatologic

RashesBruises EasilyPsoriasisEczema
Mental Status/ Emotional

DepressionAnxietyAttention Deficit DisorderBipolar DisorderSchizophreniaOther
Are you currently pregnant?

YesNo
Last Menstral Period

MonthDayYear
Date
Please upload a valid Driver's License ID and Insurance Card (if applicable).
Zazen Surgery Center

25230 Kingsland Blvd. Suite 103

Katy, Texas 77494

(p) 281-869-3011

(f) 713-561-3654
Should be Empty: