Language
English (US)
TEANECK GASTRO RECALL QUESTIONNAIRE
Drs. Schmidt, Micale, Palance, Lin & Welinsky
Todays Date
*
-
Month
-
Day
Year
Date
Patient's Full Name
*
First Name
Last Name
Patient's Age
*
Your Current Weight in pounds
*
Your Current Height
*
Have you traveled outside of the United States in the past 14 days?
yes
no
Did you receive your Covid Vaccination:
yes
no
Last Covid Vaccine Date
-
Month
-
Day
Year
Date
Are you on any anticoagulants (blood thinners) like Coumadin, Warfarin, Plavix, Lovenox, Ticlid, Aggrenox, Trental, Brilante, Pradaxa, Xarelto or Effient?
*
yes
no
If yes, who prescribed it? (name and phone number)
Do you take aspirin on a daily basis?
*
yes
no
If yes, which strength do you take?
81 mg (baby aspirin)
325 mg
If yes, who prescribed it? (name and phone number)
Why do you take aspirin daily?
Are you diabetic?
*
yes
no
If yes, what diabetic medications do you take? (name and strength)
What time of day do you take your diabetic medications?
Do you take a diuretic or water pill?
*
yes
no
If yes, what is the name of the water pill?
What time of day do you take this medication?
Do you take blood pressure or cardiac medications?
*
YES
NO
If yes, what blood pressure or cardiac medication do you take (name and strength)?
What time of day do you take the blood pressure or cardiac medication?
Who prescribed this medication? Please include name and phone number.
Do you take iron pills or vitamins that contain iron?
*
yes
no
Do you take antibiotics before going to a dentist?
*
yes
no
Are you allergic to any antibiotics?
yes
no
If yes, what antibiotic are you allergic to?
Have you been on antibiotics in the last month?
*
yes
no
If yes, for what condition did you take antibiotics?
What antibiotic were you taking?
Do you have any STENTS?
*
yes
no
Have you had rheumatic fever or heart valve replacement?
*
yes
no
Do you have congestive heart failure?
*
yes
no
Do you have an implantable defibrillator?
*
yes
no
Do you have a pacemaker?
*
yes
no
Have you had an echocardiogram, stress test, nuclear stress test, cardiac catheterization or holter monitor in the last 5 - 10 years?
*
yes
no
Do you see a cardiologist?
*
yes
no
If you do see a cardiologist, Why?
Have you had a hip, knee or joint replacement in the last six months?
*
yes
no
Are you a renal dialysis patient?
*
yes
no
Do you have a history of hepatitis or cirrhosis?
*
yes
no
Do you have lung disease, asthma, COPD (chronic obstructive pulmonary disease) or sleep apnea?
*
yes
no
Do you use supplemental oxygen?
*
yes
no
Are you over the age of 75?
*
yes
no
Since your last procedure, have you had a heart attack or stroke?
*
yes
no
Have you ever had a hard time cleaning out for your colonoscopy?
*
yes
no
Do you have ulcerative colitis or Crohn's Disease?
*
yes
no
Do you have a PICC line or porta cath in place for venous access?
yes
no
Patient Signature
*
Clear
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