Name*
Age
Date
(mm/dd/yyyy)
Address
City
State
Zip
Date of Birth (mm/dd/yyyy)
Sex
Marital Status
Home Phone*
Work Phone
E-mail Address*
NOTE: Your questionnaire will not be sent without a valid e-mail address
A. REASONS FOR COLONOSCOPY
Surveillance (Family history of colon cancer/polyps)
Screening (No symptoms)
Symptoms How Long Frequency
B. ALLERGIES/REACTIONS
C. CURRENT MEDICATIONS
Please bring a list the day of your procedure
Do you routinely take Blood Thinners NSAIDS Aspirin
D. PAST SURGERIES
E. MEDICAL HISTORY
Cardiovascular Yes No
Valve Disease Cardiac Bypass Rheumatic Fever
Automatic Implantable Cardiac Defibrillator
Respiratory Yes No
Shortness of Breath Home Oxygen Asthma
Other
Diabetic Renal Disease Hypertension History of Constipation
Infectious Disease (or recent exposure)
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MIDWEST
GASTROENTEROLOGY
CENTER
Colon Cancer Pre-Screening
Assessment Questionnaire
Please complete and press Submit - required fields are marked with an asterisk (*)
F. EMERGENCY CONTACT
Name
Relationship
Phone
Family Doctor
Phone
City
State
Zip
Should we send a copy of your screening report? Yes No
G. EMPLOYER INFORMATION
Name of Company
Address
Phone
City
State
Zip
H. INSURANCE INFORMATION
Primary Carrier (company)
Policyholder’s Name
Relationship
Group Name
Group No.
Date of Birth (mm/dd/yyyy)
Secondary Carrier (if applicable)
Policyholder’s Name
Relationship
Group Name
Group No.
I. WOULD YOU LIKE US TO SEND YOU AN INFORMATION PACKET ABOUT COLON
CANCER SCREENING? Yes No
Once we receive your questionna