Procedure History

  • Procedure History

  • Date of Birth*
     - -
  • Gender
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you have Medicare?*
  • Do you have Medicaid?*
  • Format: (000) 000-0000.
  • Subscriber's Date of Birth *
     - -
  • Do you have Power of Attorney or Guardianship over you?*
  • What is prompting you to complete this form?*
  • Physician Requested*
  • Have you ever had problems with anesthesia or difficulty being sedated?*
  • Have you ever been told that you have a difficult airway?
  • Do you have a personal history of colon polyps?*
  • Do you have a personal history of colon cancer?*

  • Cardiac History

  • Do you take any blood thinners or aspirin?*
  • Please select which blood thinners you have taken*
  • Format: (000) 000-0000.
  • Do you have an AICD/Defibrillator?*
  • Do you have a pacemaker?*
  • Do you have a mechanical valve?*
  • Do you have Heart Valve Disorder*
  • Do you have an AAA (abdominal aortic aneurysm)?*
  • Have you had a cardiac stent?*
  • Was your cardiac stent in the last 6 months?*
  • Have you had an MI (myocardial infarction)?*
  • Was your MI (myocardial infarction) in the last 6 months?*
  • Have you had a stroke/CVA or TIA?*
  • Was your stroke/CVA or TIA in the last 6 months?*
  • Do you have a history of seizures?*
  • If yes, did the seizure occur within the last 6 months?*

  • Medical History

  • Do you have a history of respiratory disease (emphysema, COPD, asthma, pulmonary fibrosis)?*
  • Can you climb a flight of stairs without being short of breath?*
  • Do you have kidney disease requiring hemodialysis or peritoneal dialysis?*
  • Do you currently take any medications for weight loss?*
  • Do you use Marijuana or any Marijuana products?*
  • Have you ever been diagnosed with esophageal varices?*
  • Are you allergic to Nickel?*
  • Do you use home oxygen?*
  • Can you walk unassisted?*
  • Past Medical History. Please select all that apply.*
  • Past Surgical History. Select all that apply.*
  • Current GI symptoms*
  • Should be Empty: