Colon Cancer Pre-Screening Assessment Questionnaire.pdf

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City State Zip mm dd yyyy Birth mm dd colon cancer Screening MIDWEST GASTROENTEROLOGY CENTER Phone City State INFORMATION Phone Screening Relationship Group

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)
	
	
	
          (please go to page 2)	
 
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 questionnaire, the confidential information will be reviewed and a medical
staff member will verify all information and schedule your colon cancer screening.
                             Please press Submit only ONCE to send your form to us
SUBMIT
MIDWEST
  GASTROENTEROLOGY
      CENTER