Gastroenterology Screening Form

First Name

Last Name

Gender Assigned at Birth

Birth Date

Street Address

City

State

Zip Code

Email Address

Phone Number

Referring physician

Have you ever had a colonoscopy in the past?

YesNoI'm not sure

When?

Where?

Is the report available?

Do you have a personal history of colon polyps/cancer?

YesNoI'm not sure

Do you have a family history of colon cancer or polyps?

YesNoI'm not sure

What is your relationship to the family member who has had colon cancer or polyps?

At what age was the family member diagnosed?

Are you having any bowel changes (i.e. diarrhea, constipation, blood in stool)

YesNoI'm not sure

Do you have any of the following?

Frequent heartburnDysphagiaChronic PPI useFrequent blood in stoolsChange in bowel habitsChronic constipationChronic diarrhea

Please provide any additional comments you would like us to know about your current health.

Past Health History

COPD/Asthma YesNo	Kidney problems YesNo
Diabetes YesNo	Stroke/TIA YesNo
Seizures YesNo	HIV YesNo
Hepatitis B/C YesNo	Liver problems/cirrhosis YesNo
CAD/Stents YesNo	Pacemaker/AICD/Arrhythmia YesNo
Sleep Apnea YesNo	MRSA or VRE YesNo

Complete list of medications including dose, especially diabetic meds/blood thinners, NSAIDs

Allergies:

Check the below box if you understand the patient must check with insurance for coverage.

I understand

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