• Screening Colonoscopy Questionnaire

  • If you need help with the form below, call 410-641-9257.
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Do you have a MyChart Account*
  • Gender
  • Race/Ethnicity
  • Have you ever had a colonoscopy (a test to look at your colon)?*
  • Do you have a personal history of colon polyps?*
  • Have you had a positive Cologuard test in the past three years?

  • Where was your last procedure?                                                      

  • Do you have an immediate family history of colon cancer?*
  • Who?*
  • Do you have any stomach issues or concerns that you would need to see a gastroenterology (GI doctor) for?*
  • Do you have a history of Crohn's disease, ulcerative colitis, or cirrhosis?*
  • Are you on a weight loss drug?*
  • Do you have any heart problems?*
  • Are you taking any blood thinners, other than aspirin, such as:*
  • Have you seen a heart doctor (cardiologist) in the last one-to-two years?*
  • Do you have any breathing problems or concerns (asthma, COPD, shortness of breath, etc.)?*
  • Have you had an ER visit in the last 6 months for this?*
  • Do you oxygen at home and need 4L or more?*
  • Do you have sleep apnea (trouble breathing while sleeping)?*
  • Do you use a CPAP machine?*
  • Do you have trouble lying flat because of trouble breathing or shortness of breath?*
  • Have you had a seizure in the last month?*
  • Have you ever been told you have renal or kidney disease?*
  • Are you currently on dialysis?*
  • Does anyone in your family have a history of a serious reaction to anesthesia?*
  • Have you had problems with anesthesia (like trouble being put to sleep or waking up from surgery) or have you been told you have a difficult airway?*
  • Do you need help getting out of a chair or walking a short distance?*

  • Height:   *      

  • Should be Empty: