Colonoscopy Intake Form

Colonoscopy Intake Form

Welcome to the CRSGH colonoscopy intake form. Our goal with this form is to streamline the work-up process for routine colonoscopies while reducing unnecessary office visits for patients. Please answer each question to the best of your ability. Questions with a red asterisk require a response. Write "none" if these fields do not apply to you. Based on your answers to these questions, you may still be asked to attend a telehealth or in person visit to review your history. Please note, if you are already scheduled for a colonoscopy- you do not need to fill out this form.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Alternate Phone Number
Email*
example@example.com
Date of birth*

MonthDayYear
Date
Gender*

MaleFemaleOther
Please enter your weight and height.*
Have you received the COVID-19 vaccine?

YesNo
Race
Who is your primary care doctor?*
Please list all allergies and their reactions below.*