Direct Schedule Colonoscopy
Gender
Patient's Full Name
*
First Name
Last Name
Phone Number
*
E-mail
*
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Height in Inches
Weight in Pounds (lb)
Primary Care Doctor
Pharmacy Name
Insurance Carrier
Member ID #
Group ID #
Name of Insured
Insured Date of Birth
Relationship
Insurance Customer Service Phone
Have you had Colonoscopy in the past?
Yes
No
If yes, where and when was it performed?
What were the results of the prior exam?
Polyps
Cancer
Ulcerative Colitis
Crohn's Disease
Other
Do you have a family history of Colon Cancer or Colon Polyps?
Colon Cancer
Colon Polyps
None
If you have a family history of Colon Cancer or Colon Polyps, which relatives were diagnosed?
Are you allergic to any medications?
Yes
No
If you have any drug allergies, please list them below (Include any latex or tape allergies)
Do you take any Aspirin or Blood thinner medications?
None
Aspirin
Plavix (Clopidogrel)
Effient
Brilinta
Coumadin (Warfarin)
Xarelto
Pradaxa
Eliquis
Other
Name of the physician who prescribed the medication
Please list all medications below including any over-the-counter medications, natural medications, vitamins and supplements
Are you currently experiencing or recently experienced any symptoms such as weight loss, abdominal (belly) pain, blood in the stool, black stool, heartburn requiring regular use of medicines, constipation, diarrhea or any change in your bowel habits?
Yes
No
Have you ever been told that you are anemic? (have a low blood count)
Yes
No
Do you have a pacemaker or implanted defibrillator device?
Yes
No
Have you ever been diagnosed with an Inflammatory Bowel Disease such as Crohn's Disease or Ulcerative Colitis?
Yes
No
Do you take any Aspirin or Blood thinner medications?
Stent Placement
Heart Attack (MI), Congestive heart Failure (CHF) or Arrhythmia (Irregular Heartbeat)
Seizures or Fainting Spells
Stroke
Sleep Apnea or other chronic respiratory illness such as Asthma, COPD or Emphysema
Diabetes
Thyroid Disorders
Obesity
Kidney Disease with or with out Dialysis
Organ Transplant
Anemia (Low Blood Count)
Other
Submit
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