First Name *

Last Name *

Date of birth *

Phone *

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Referring Provider

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

Anesthesia History

KNOWN difficult airway/intubation

Personal or family history of malignant hyperthermia

Latex allergy

Any prior complications related to anesthesia or sedation

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

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

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

Yes

Females: Are you currently pregnant? *

Yes

Cardiac/Pulmonary History (check all that apply)

Chest pain in the last MONTH

Cardiac stents, myocardial infarction (heart attack) or CABG (bypass surgery) in the last 6 months

History of significant/frequent heart failure or shortness of breath

AICD (defibrillator) placement.

Stroke or TIA (transient ischemic attack) in the past 6 months

Home oxygen >2L day or night

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?