First Name *

Last Name *

Date of birth *

Phone *

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What is the reason for your colonoscopy? *

Screening (no family history)

Screening (family history of colon cancer)

Screening (family history of advanced precancerous polyps)

Screening (positive stool screening test)

Surveillance (prior colon polyps)

Surveillance (prior colon cancer)

Symptoms (blood in stool, change in bowels, abdominal pain etc.)

Is the patient in a facility (nursing home, assisted living etc.)? *

Yes

Have you ever had complications with anesthesia or sedation? *

Yes

Do you have sleep apnea and do not use a CPAP machine? *

Yes

Is your Body Mass Index (BMI) greater than 50, or is your weight greater than 400 pounds? *

Yes

Have you had chest pain, shortness of breath, or fainting with minimal activity or at rest in the past 6 months? *

Yes

Are you currently on dialysis or other renal replacement therapy? *

Yes

Do you have an inplantable cardiac defibrillator (ICD)? *

Yes

Have you had a heart attack or stroke in the last 12 months? *

Yes

Have you had an infection such as c.diff, MRSA, or VRSA in the past 12 months? *

Yes

Females: Are you currently pregnant? *

Yes

Are you currently taking a blood thinner? *

Yes

Health History (Check all that apply)

Are you currently taking a blood thinner (such as warfarin, Plavix, Eliquis, Xarelto, Pradaxa)?

Do you take a once weekly injection for Diabetes or weight loss?

Do you take a SGLT2 medication (commonly used for diabetes, chronic heart failure, or chronic kidney disease)?

Do you take any ORAL prescription weight loss medications?

Do you take Naltrexone?

Have you had a prior colonoscopy elsewhere?

Do you require a language interpreter?

Do you have chronic constipation?