Open Access Colonoscopy Program Medical Questionnaire | Charlotte Gastroenterology and Hepatology

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NAME
ADDRESS
CITY, STATE, ZIP
PHONE ( DAY )
MOBILE
DOB, PRIMARY CARE MD
INSURANCE CARRIER
MEMBER ID# / GROUP#
INSURED NAME / RELATIONSHIP
INS. CUST. SERV. TEL#
LOCATION REQUESTED
PHYSICIAN REQUESTED
PAYMENT METHOD	SELF-PAY NO INSURANCE
WHO ARE WE ALLOWED TO CONTACT IN THE EVENT YOU ARE UNAVAILABLE?

RE: PROCEDURE CONFIRMATION & HIPAA COMPLIANCE
Please list any active medical problems
Please list all medications (include over the counter products)
It is important that patients 65 and older have a history and physical on file with their primary care physician within 30 days of their Open Access Colonoscopy. This can be easily obtained through your primary care provider. Have you met that criteria?
Yes No Date of exam MD
Do you take blood thinning medication? (coumadin, aspirin, or plavix) Yes No
Do you have any allergies to medications? Yes No Please list.

Please check Yes or No in answer to the following medical history questions.
*Heart Disease*
Yes No Coronary Artery Disease/Angina/HeartAttack
Yes No Congestive Heart Failure
Yes No Valvular Heart Disease/Artificial Heart Valve

*Lung Disease*
Yes No Emphysema, COPD, Asthma, or Bronchitis requiring regular medical therapy
Yes No Sleep Apnea

*General Health*
Yes No Kidney Disease
Yes No Stroke
Yes No Diabetes
Yes No Do you take antibiotics when going for dental work?
Yes No Have you had a joint replacement within the last year?
Yes No Have you ever had a complication with anesthesia?
Yes No Do you weigh more than 350 pounds?

*Gastroenterology*
Yes No Do you have heartburn more than twice a week?
Yes No Do you see blood in your bowel movements?
Yes No Do you have frequent constipation or diarrhea?
Yes No Do you have relatives with colon cancer? Who?

Offices in:

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