GI Procedure Scheduling Questionnaire

GI Scheduling Questionnaire
Date

MonthDayYear
Name

First NameLast Name
Day Time Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Insurance Carrier
Insurance Group Number
Insurance Policy #
Insurance Phone Number
Format: (000) 000-0000.
Insurance Claim PO Box Address

PO Box

Street Address Line 2

CityState

Zip Code
Insurance Policy Holder Name
Insurance Policy Holder's Birth Date

MonthDayYear
Date
Insurance Policy Holder Relationship to you
Referring Provider
PCP
Date of Birth

MonthDayYear
Age
Height
Feet and Inches
Weight
LBS
Are you a new patient to Boulder Medical Center
Have you had your primary care provider fax your medical history and last physical to (303) 440-3097?
Pharmacy Phone Number
Format: (000) 000-0000.
Preferred Pharmacy
What procedure are you looking to schedule?
Why are you having an EGD?
When was your last EGD?
Where was your last EGD done?

Name of Facility
Have you ever had esophageal varies?
Where was your last colonoscopy done?

Name of Facility
When was your last colonoscopy?
Have you ever had polyps removed or a biopsy done?
DO YOU HAVE ANY OF THE FOLLOWING PROBLEMS? **If you answer YES to any of the questions, you are required to provide us the most recent medical records(s) from your provider before we can schedule your procedure.
Kidney
Do you have ankylosing spondylitis
Please provide details about your kidney issues:
Diabetes
Cardiac
Do you have a pacemaker?
Do you wear an ACID?
Who is your Cardiologist?
Lung
Do you have sleep apnea?
Do you use a CPAP machine?
Do you use oxygen?
Do you take any medications for diabetes orweight loss:
Please list the diabetes or weight loss drugs you are taking:
Have you had previous problems with Anesthesia?
Please provide details about your anesthesia issues:
Calculation
Should be Empty:

GI Scheduling Questionnaire

DO YOU HAVE ANY OF THE FOLLOWING PROBLEMS? **If you answer YES to any of the questions, you are required to provide us the most recent medical records(s) from your provider before we can schedule your procedure.