Procedure History
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
Female
Male
Prefer not to say
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Referring Physician or Primary Care Physician (First/Last name)
*
Referring Physician Phone Number
*
Please enter a valid phone number.
Pharmacy Name, Pharmacy City
*
Pharmacy Phone Number
*
Please enter a valid phone number.
Do you have Medicare?
*
Yes
Yes, Part A only
No
What is your Medicare number?
Do you have Medicaid?
*
Yes
No
Primary Insurance Company Name
*
Insurance ID
*
Please enter all letters and numbers
Group ID (if none, enter N/A)
*
Insurance Phone Number (from the back of your insurance card)
*
Please enter a valid phone number.
Address found on the back of your insurance card
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Subscriber's Name (i.e., Who is the Insurance Policyholder)
*
First Name
Last Name
Subscriber's Date of Birth
*
-
Month
-
Day
Year
Date
Secondary Insurance Company Name (if applicable, enter N/A if none)
*
Secondary Insurance ID (if applicable, enter N/A if none)
*
Secondary Insurance Group ID (if applicable, enter N/A if none)
*
Do you have Power of Attorney or Guardianship over you?
*
Yes
No
If yes, then Who? (Documentation is required at check-in at the time of your procedure)
First Name
Last Name
What is prompting you to complete this form?
*
Recall letter received in mail
Screening Colonoscopy
New procedure referral
Physician Requested
*
No preference
Mohammed Barawi, MD
Kerri Bewick, DO
Richard Cascio, MD
Satyajit Daniel, MD
Sudhanshu Patel, MD
Leonid Shamban, DO
Have you ever had problems with anesthesia or difficulty being sedated?
*
Yes
No
Have you ever been told that you have a difficult airway?
Yes
No
Back
Next
When was your last Colonoscopy? Where did you have it done?
*
Do you have a personal history of colon polyps?
*
Yes
No
Do you have a personal history of colon cancer?
*
Yes
No
Do you have a family history of polyps? If yes, state their relation to you and age at diagnosis.
*
Do you have a family history of colon cancer? If yes, state their relation to you and age at diagnosis.
*
When was your last Upper Endoscopy (EGD)? Where did you have it done?
*
Cardiac History
Do you take any blood thinners or aspirin?
*
Yes
No
Please select which blood thinners you have taken
*
Aspirin 81mg
Aspirin 325 mg
Coumadin (Warfarin)
Xarelto (Rivaroxaban)
Eliquis (Apixiban)
Plavix (Clopidogrel)
Lovenox
Pradaxa
Brilinta (Tircagrelor)
Effient (Prasugrel)
Please list your Cardiologist's first/last name (if applicable, enter N/A if none)
*
Cardiologist's Phone Number
Please enter a valid phone number.
Do you have an AICD/Defibrillator?
*
Yes
No
Do you have a pacemaker?
*
Yes
No
What is the manufacturer of your pacemaker?
*
Do you have a mechanical valve?
*
Yes
No
Do you have an AAA (abdominal aortic aneurysm)?
*
Yes
No
If yes, what is the size (cm)?
*
Have you had a cardiac stent?
*
Yes
No
Was your cardiac stent in the last 6 months?
*
Yes
No
Have you had an MI (myocardial infarction)?
*
Yes
No
Was your MI (myocardial infarction) in the last 6 months?
*
Yes
No
Have you had a stroke/CVA or TIA?
*
Yes
No
Was your stroke/CVA or TIA in the last 6 months?
*
Yes
No
Do you have a history of seizures?
*
Yes
No
If yes, did the seizure occur within the last 6 months?
*
Yes
No
Medical History
Height (Feet, inches)
*
Height MUST be accurate. Patient BMI determines the most appropriate location for your procedure. Procedures will be canceled if BMI does not meet procedure center guidelines.
Weight (lbs./pounds)
*
Weight MUST be accurate. Patient BMI determines the most appropriate location for your procedure. Procedures will be canceled if BMI does not meet procedure center guidelines.
Do you have a history of respiratory disease (emphysema, COPD, asthma, pulmonary fibrosis)?
*
Yes
No
Can you climb a flight of stairs without being short of breath?
*
Yes
No
Do you have kidney disease requiring hemodialysis or peritoneal dialysis?
*
Yes
No
Do you currently take any medications for weight loss?
*
Yes
No
If diabetes medication is being taken, please list medication and dosage. (If none, enter N/A)
*
Please list all Medications that you are currently taking. If none, enter N/A.
Do you use Marijuana or any Marijuana products?
*
Yes
No
Please list your medication allergies and reactions. If none, please enter N/A.
*
Do you use home oxygen?
*
Yes
No
Can you walk unassisted?
*
Yes
No
Past Medical History. Please select all that apply.
*
No medical history
Hypertension
Hyperlipidemia (high cholesterol)
Arrhythmia
Diabetes
COPD
Chronic Kidney Disease
Multiple Sclerosis
HIV/AIDS
Coronary artery disease (heart disease)
CHF (congestive heart failure)
Atrial Fibrillation
Asthma
Obstructive Sleep Apnea
Cirrhosis
Parkinson's
Myasthenia Gravis
Bleeding disorder (Von Willebrand's, Factor V, MTHFR gene, or ITP gene)
Past Surgical History. Select all that apply.
*
No surgical history
Hysterectomy
Cardiac Stents
Bowel resection
Bariatric/Weight loss surgery
Prostatectomy
Neck fusion (ABLE to touch chin to chest)
Neck fusion (UNABLE to touch chin to chest)
Cholecystectomy (gallbladder removed)
CABG/Cardiac bypass surgery
Cardiac Valve Replacement
Other Surgeries
Current GI symptoms
*
No Current Symptoms (Screening or Preventative)
Positive stool test
Positive Cologuard
Positive FOBT
Positive FIT Test
Rectal Bleeding (black stools)
Unintentional weight loss
Bloating
Diarrhea
Constipation
Rectal bleeding (bright red)
Abdominal Pain
GERD/Heartburn
Food getting stuck/trouble swallowing
Nausea/Vomiting
Is there anything else you'd like us to know before we schedule your scope?
*
Disclaimer: By submitting this form, I agree that these questions have been answered honestly and to the best of my knowledge. I understanding that providing inaccurate information could result in complications during my procedure. I agree to contact the office and speak with a nurse if I have any health information, medication changes or cardiac work-up prior to my scheduled procedure. Please write your initials below.
*
Submit
Should be Empty: