Check All That Apply
ColonoscopyUpper Endoscopy

Patient Name *

Patient Date of Birth *

Gender *
MaleFemaleOther

Height

Weight

Patient Home Phone *

Patient Cell Phone

Patient Address

Street Address

Address Line 2

City

State

Zip Code

Country

Patient Email *

Current History

If you have requested a screening or recall colonoscopy, it is important that you are not currently experiencing any of the following: Rectal bleeding; persistent abdominal pain; sudden change in bowel habits; or persistent diarrhea. If you are currently having any of these symptoms, please call our office at 859-655-4480 to schedule an appointment with a practitioner. These symptoms will not allow you to qualify for a “screening colonoscopy” with your insurance company.

Current Medications (Please include prescrition, over the counter, and herbal medications)

Are you currently experiencing any rectal bleeding, abdominal pain, diarrhea? *
Rectal BleedingAbdominal PainDiarrheaNone

* If Yes, we are not able to schedule a procedure at this time. Please call our office 859-655-4480 to schedule an office visit.

Do you have any allergies or sensitivities to any medications? *
YesNo

If Yes, Please list medications and include reaction to each:

Do you take any medication that thins your blood (such as Coumadin, Plavix, Pradaxa, Aspirin, etc.) *
YesNo

If Yes, please list any Blood-thinners:

Cardiologist/Prescribing Doctor:

Cardiologist/Prescribing Doctor Phone Number:

Within the last 3 months have you had any of the following?
DiverticulitisProstate BiopsyGastric BypassHeart Bypass or StentHeart AttackChest PainRectal BleedingAbdominal Pain

Are you Diabetic? *
YesNo

Do you have any history of seizures? *
YesNo

Are you currently on dialysis? *
YesNo

Are you allergic to Latex? *
YesNo

If Yes, Please list details of latex reaction:

Have you recently been exposed to or are you currently being treated for any communicable diseases such as TB / Lice / MRSA / Bed Bugs / Ebola Virus
YesNo

If Yes, Communicable diseases comments:

Any Mobility Issues?
YesNo

If Yes, please explain:

Do you have any allergies to eggs? *
YesNo

If Yes, Egg Reaction Comments:

Have you had a heart attack in past 3 months? *
YesNo

Do you have a severe pulmonary disease such as COPD? *
YesNo

Do you use daytime oxygen?
YesNo

Is there any possibility you could be pregnant? *
YesNoUnknownN/A

Are you currently on a MAO Inhibitor for depression or Parkinson’s? *
YesNo

* MAOI’s that interact with sedation:
Generic -> Brand name
Isocarboxazid -> Marplan
Phenelzine Sulfate -> Nardil
Tranylcypromine -> Parnate
Selegline -> Emsam, Eldepryl, Zleapar

Do you currently using the medication Phentermine for weight loss? *
YesNo

Do you have any special needs when you come to the office?
NoneHard of HearingDeafHearing Aid(s)BlindOxygenC-Pap for Sleep ApneaWheelchairWalker/CanePortacathPic LineOther

Chief Complaint (Reason for Appointment) *

*Please note if you are submitting this form electronically, your typed signature serves the same as a written signature.