Schedule A Procedure

Patient Pre-Procedure History Form

  • Please complete all areas of this form.
  • If something does not pertain to you, write N/A.
  • Return this form to our office as soon as completed.


Call 859-655-4490, leave a message and your call will be returned. If you are completing online, select “submit” at the bottom of the form and it will be e-mailed to us.

    Check All That Apply

    Patient Date of Birth *

    Gender *



    Patient Home Phone *

    Patient Cell Phone

    Patient Address

    Street Address

    Address Line 2



    Zip Code


    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? *

    * 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? *

    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.) *

    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?

    Are you Diabetic? *

    Do you have any history of seizures? *

    Are you currently on dialysis? *

    Are you allergic to Latex? *

    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

    If Yes, Communicable diseases comments:

    Any Mobility Issues?

    If Yes, please explain:

    Do you have any allergies to eggs? *

    If Yes, Egg Reaction Comments:

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

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

    Do you use daytime oxygen?

    Is there any possibility you could be pregnant? *

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

    * 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? *

    Do you have any special needs when you come to the office?

    Chief Complaint (Reason for Appointment) *

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