Self-Referral Colonoscopy Questionnaire

Self-Referral Colonoscopy Online Questionnaire

All information submitted on this questionnaire will be reviewed.

Please allow up to 5-7 business days before you receive a return telephone call to schedule the procedure and receive pre-procedure colonoscopy and preparation instructions.

If after review of the submitted information, our staff finds that the patient is not eligible for self-referral Colonoscopy, we will contact the patient to schedule a clinic appointment.

First Name:
Last Name:
Date of Birth:

Email Address:

Mailing address to receive prep and procedure instructions:

Address line 2

City

State

Zip code

Daytime Phone number

Evening Phone Number

Referring/Primary Care Provider

Referring/Primary Care Provider Phone #

Insurance Plan:

Insurance ID#:

Insurance Group#:

Insured:

Group Name:

Preferred Pharmacy:

Reason for Visit:

Procedure Being Requested: Colonoscopy

Ethnicity/Race: CaucasianAfrican-AmericanAsian Pacific IslanderHispanicRace Unknown

Sex:

Height:

Weight:

If female, have you reached menopause? YesNo
Are you a female of child bearing age? YesNo

NSAID use: Advil, Motrin (Ibuprofen); Aleve (Naproxen sodium); Ascriptin, Bayer, Ecotrin (aspirin); Anaprox (naproxen sodium); Celebrex (celecoxib, sulindac); Daypro (oxaprozin, salsalate, diflunisal); Feldene (piroxicam) Indocin (indomethacin, etodolac); Mobic (meloxicam); Naprosyn (naproxen, nabumetone, ketorolac tromethamine); Vimovo (naproxen/esomeprazole); Voltaren (diclofenac)

Anti-coagulant use: (Plavix, Coumadin, Heparin, Lovenox, Pradaxa, Refludan, Arixtra, Xarelto, Eliquis, etc.)

Allergies:

Please list current medications and dosages:

Medical History

Previous colon cancer screening: Barium EnemaFlex SigmoidoscopeColonscopy

Date of last colonoscopy? None<5 yearsAlmost 5 years6-9 years>10 years

What provider performed last colonoscopy procedure?

Result of Colonoscopy?
NoneFailed/Incomplete ExamNo Polyps<3 Polyps3-5 Polyps>5 Polyps

Do you feel you need to be evaluated for any of the following GI symptoms?
Blood in Stool (K92.1)Rectal Bleeding (K62.5)Abdominal Pain (R10.9)Constipation (K59.00)Diarrhea (R19.7)Unexplained Weight Loss (R63.4)

Pulmonary History?
Shortness of BreathCOPDAsthmaCoughSleep Apnea

Do you use a CPAP? YesNo
Have you had a heart attack? YesNo
Do you have a defibrillator or pacemaker? YesNo
Are you diabetic? YesNo

Have you had any previous surgeries? If so, please list:

Prior difficulty with anesthesia or sedation? YesNo
If yes, explain:

Do you drink alcohol: Amount (1 can of beer, 1 glass of wine, 1 shot of spirts = 1 drink)
None<4 drinks a yearUp to 3 drinks/week4-13 drinks/week14 or more drinks/week

Did you ever smoke? YesNo
How many packs/day did you smoke?

Have you quit smoking? YesNo

Do you have a parent or sibling who had colon cancer or rectal cancer?
YesNo
If yes, please put relationship and age at their diagnosis:

Please add any comments: