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.*

Do you have a Latex allergy?*

YesNo
Please list your current medications, including dose and frequency. *
Include over the counter, prescription, and vitamins/supplements.
Do you take any blood thinners? (Coumadin, Plavix, Lovenox, Aspirin) If yes, please list why you take the medication.*
Please list any surgeries you have had in the past:*
Include dates if possible
Have you ever had problems with anesthesia in the past? If so, please explain.*
Do you use any of the following?*

AlcoholCocaineIV drugsMarijuanaNicotineOtherNone of the above
If you answered yes to any of the above, please state how often you use each substance.
Who referred you to CRSGH for colonoscopy?*
Doctor, friend, self, website etc.
What is the reason for your colonoscopy?
Screening, follow up to prior colonoscopy, other.
Have you ever had a colonoscopy in the past? If so, when and with whom?*
Did you have any problems with your prior colonoscopies?
Incomplete, poor prep, bleeding.
Have you ever had a polyp, rectal cancer, or colon cancer?
Have you ever had an upper endoscopy in the past? If yes, please list the dates/reason.
Do you have any concerns or changes with your bowels?
Bleeding, constipation, diarrhea, abdominal or rectal pain, unintentional weight loss, bloating.
Does anyone in your family have history of rectal cancer, colon cancer, polyps, ulcerative colitis or Crohn's disease? *
If yes, please specify who in your family, and what history they have.
Do you/have you had any of the following:*

AnemiaAnxiety/depressionArthritisArtificial joints, rods, pins or platesAsthma/BronchitisAutoimmune disordersBleeding disordersBlood clotCommunicable diseases (TB, flu, MRSA, c. diff, COVID)COPD/EmphysemaCrohn's diseaseDiabetesHeart AttackHeart FailureHigh blood pressureHigh cholesterolHistory of fallsIrritable Bowel SyndromeIrregular Heartbeat/ Atrial fibrillationKidney conditions/failureLiver diseaseNeurologic conditionsPacemaker/defibrillatorSeizuresSkin conditions/woundsSleep ApneaStrokeThyroid conditionsUlcerative ColitisNone of the above
If you answered yes to any of the above, please include any information you may feel is important. (Doctors names, dates, tests or treatments). Also include any history not included on the list above.
Have you ever seen a cardiologist? If so, who?
Have you had any other types of cancer?
Have you ever had an echocardiogram? If so, when?
How many flights of stairs can you climb before feeling tired or winded?

012345+
Do you require any of the following:

Contact lensesDenturesGlassesHearing AidsWalker/CaneWheelchairOther
Are you pregnant, or could you possibly be pregnant?*
Do you have any religious or cultural needs?
Do you have a preference for which provider performs your colonoscopy?
You may write in a provider, male, or female if this is important to you.
Please attach a photo of the front of your insurance card. *

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Please attach a photo of the back of your insurance card. *

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Please attach a photo of the front of your SECONDARY insurance card.

Cancelof
Please attach a photo of the back of your SECONDARY insurance card.

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Please attach a photo of your drivers license or state ID card. *

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Please attach a photo of your drivers license or state ID. *
Please attach a photo of the back of your insurance card. *
Please attach a photo of the front of your SECONDARY insurance card.
Please attach a photo of the back of your SECONDARY insurance card.
Please provide the name and address of your preferred pharmacy:*
If there is any information which you feel the need to add, please include it here:
Thank you for entrusting us with your care. For further information about our providers, facilities, and colonoscopy preparation instructions please visit our website at www.CRSGH.com.

Please note: Any information submitted using this form is transmitted securely and held in the strictest of confidence, protecting your privacy.
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