Screening Colonoscopy Questionnaire
If you need help with the form below, call 410-641-9257.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Age
*
Have you ever had a colonoscopy (a test to look at your colon)?
*
Yes
No
If yes, do you have a personal history of colon polyps?
*
Yes
No
I don't know. I've never had a colonoscopy.
Do you have any stomach or digestion problems?
*
Yes
No
Do you have any heart problems (like a heart condition or heart failure, or have you had a stent or pacemaker)?
*
Yes
No
Have you seen a heart doctor (cardiologist) in the last six months?
*
Yes
No
If you answered 'yes' to the previous question, please provide the name of your cardiologist. Otherwise, type in 'NA.'
*
Do you have any breathing problems like asthma or COPD?
*
Yes
No
Have you gone to the ER for breathing problems within the last six months?
*
Yes
No
Do you have sleep apnea (trouble breathing while sleeping)?
*
Yes
No
If you have sleep apnea, do you use a CPAP machine like your doctor told you to?
*
Yes
No
I don't have sleep apnea
Are you taking any blood thinners (other than aspirin), like Plavix, Warfarin, Eliquis, or Xarelto?
*
Yes
No
Do you have trouble lying flat because of trouble breathing?
*
Yes
No
Do you have a seizure disorder?
*
Yes
No
If you have seizures, have you had one in the last month?
*
Yes
No
I don't have a seizure disorder
Do you need dialysis (treatment for your kidneys)?
*
Yes
No
Does anyone in your family have a history of a serious reaction to anesthesia?
*
Yes
No
Do you use oxygen at home, and need more than 4 liters?
*
Yes
No
Not sure
Do you have trouble doing everyday tasks, like getting dressed, taking a shower, or getting up from a chair or bed?
*
Yes
No
Have you ever been told you have an infection called MRSA or C.diff?
*
Yes
No
Have you had problems with anesthesia (like difficulty with being put to sleep for surgery)?
*
Yes
No
How much do you weigh (in pounds)?
*
Height:
feet
*
inches
Submit
Should be Empty: