Scheduled Procedure Screening Form

Please fill out this Scheduled Procedure Screening Form. A Registered Nurse will call you to review once you have completed it. All of your information will be sent securely, utilizing secure SSL technology. Your personal information will be safe, secure and kept private.

if you have already spoken to a
pre-call nurse at the facility and
provided this information.

Patient Information

First Name:
Last Name:
Procedure Date:
Procedure Time:
Date Of Birth:
Zip Code:
Home Tel:
Work Tel:
Best number and time to reach you?

If you would rather give us your information over the phone, please complete the above section only and then scroll to the bottom of the page and click the "Submit" button. We will contact you at the number and best time to reach you that you have indicated.

Your procedure is being performed by:

Dr. Atta-Mensah
Dr. Gazi
Dr. Lewis
Dr. Rossi
Dr. Banerjee
Dr. Goldenberg
Dr. Munsaf
Dr. Stone
Dr. Dharan
Dr. Hoffman
Dr. Petruff
Dr. Van Linda
Dr. Zaldonis

Procedure Type


Indication for procedure:

  • Screening
  • Change in bowel habits
  • Abdominal Pain
  • IBD
  • Gerd
  • Dysphagia
  • History of Polyps
  • GI Bleeding
  • Other
  • Crohn's
  • Ulcerative Colitis
  • Family history of colon cancer
  • Rectal Bleeding

Who will be driving you home?

Contact phone number:

Patient Race

White or Caucasian
Native Hawaiian or Pacific Islander
Black or African America
Native Alaskan - American Indian
Decline to Answer

Patient Ethnicity

Hipanic or Latino
Not Hipanic or Latino
Declined to Answer

Primary Language

Is your primary language English? Yes No
If no, what is your primary language?
Interpretor needed? Yes No N/A

Insurance Information

Who is your insurance provider?
Secondary Insurance Provider
Group Number
ID Number
Group Number
ID Number
Primary Doctor?
GI Doctor?

Patient Demographics


Health History

What is your gender?


Have you ever seen a cardiologist? Yes No
Cardiologist Name
Cardiologist Number
Date of last Cardiologist visit
Cardiovascular diagnoses:
  • Abnorm rhythm
  • Chest pain
  • High Cholesterol
  • MI / Heart Attack
  • Rheumatic fever
  • Artificial Valve
  • CHF
  • High Blood Pressure
  • Pacemaker
  • Valvular disease
  • Cardiomyopathy
  • CAD
  • Defibrillator
  • Peripheral edema
  • Other


Do you have any pulmonary/breathing conditions? Yes No
Pulmonary diagnoses:
  • Asthma
  • COPD
  • Pneumonia
  • Sleep apnea
  • Tracheotomy
  • Bronchitis
  • Emphysema
  • Productive cough
  • SOB
  • Recent URI
  • Tuberclosis
  • Other
Do you have a pulmonologist? Yes No Pulmonologist Name:


Do you have any GI conditions? Yes No
GI diagnoses:
  • Previous Colonoscopy
  • Colitis
  • Crohn’s Disease
  • Personal Hx colyn polyps
  • Family Hx colon cancer
  • Family Hx of colyn polyps
  • Abdominal pain
  • Diarrhea
  • Hemorrhoids
  • Rectal Bleed
  • Celiac
  • Cirrhosis
  • Hepatitis
  • Jaundice
  • Unexplained weightloss
  • Ulcers
  • Anemia
  • Other
  • Previous Endoscopy
  • Barrett’s Esophagus
  • Gastric reflux
  • Epigastric Pain
  • Heartburn
  • Dysphagia
  • Dyspepsia
  • Hiatal hernia
  • Nausea
  • Vomiting


Do you have diabetes? Yes No
Treated with:
  • Diet
  • Insulin
  • Insulin Pump
  • Oral medication

Renal / Endocrine

Do you have any Renal or Endocrine conditions? Yes No
Endocrine diagnoses:
  • Dialysis
  • Thyroid problem
  • Kidney stones
  • Prostate
  • Renal insufficiency
  • Other

Neuro / Muscoskeletal

Neuro / Musculoskeletal Diagnoses: Yes No
Neuro / Muscoskeletal Diagnoses:
  • Acident / Injury
  • Headaches
  • MS
  • Prosthesis
  • TMJ
  • Amputation
  • Limited ROM
  • Neck/Back pain
  • Seizure disorder
  • TIA / CVA
  • Arthritis
  • Migraines
  • Paralysis
  • Stroke
  • Other


Do you have any of the below conditions? Yes No
Other diagnoses:
  • Anemia
  • Cancer
  • Hepatitis A/B/C
  • STD
  • Auto immune
  • Chemotherapy
  • Lupus
  • Steroid use
  • Bleeding disorder
  • Obesity
  • Glaucoma
  • Other

Mental Health

Do you have any mental health conditions? Yes No
Psychiatric diagnoses:
  • Anxiety
  • Depression
  • Other

Pregnancy status

Are you pregnant? Yes No N/A
Last menstrual cycle (approximately)

International Travel

Have you been out of the country in the last 30 days? Yes No N/A
Comments: Where / When Return / How long?

Recent Illness or Infection

Have you been recently ill? Yes No
Comments about recent illness:
Any antibiotics in past 2 weeks? Yes No N/A
Any steroid use? Yes No N/A

Hospital Acquired Infection

Have you acquired a hospital infection? Yes No
Type of hospital acquired Infection:
  • MRSA
  • VRE
  • C-Diff
  • Other

Surgical History

Previous non-GI surgery

Have you had previous non-GI surgery? Yes No
Type of Surgery:
  • Arthscopy
  • Carpal tunnel
  • Hysterectomy
  • Laparscopy
  • Wisdom Teeth Extraction
  • C-Section
  • Hernia repair
  • Joint replacement
  • T & A
  • CABG
  • Hip replacement
  • Knee replacement
  • Valve rep
  • Other

Previous GI surgery

Have you had previous GI surgery? Yes No
Type of Surgery:
  • Appendectomy
  • Bilroth I Gastrectomy
  • Total Colectomy
  • Hiatal Hernia Repair
  • Bariatric
  • Bilroth II Gastrectomy
  • Hemicolectomy, left
  • Nissen Fundoplication
  • Bowel resection
  • Cholecystectomy / Gall bladder removal
  • Hemicolectomy, right
  • Other

History of problems with anesthesia

Have you had any negative reactions to anesthesia? Yes No
Anesthesia reactions:
  • Allergic reaction
  • Hyperthermia
  • Persistent vomiting
  • Unstable BP
  • Fainted
  • Hypotension
  • Prolonged sedation
  • Hyperexcitability
  • Persistent Nausea
  • Tachycardia
  • None
  • Other
Anesthesia Comments:

History of difficult airway

Do you have a history of difficult airway or placing a breathing tube for any surgeries? Yes No
Comments about difficult airway:

Implants/Prosthetics/removable dental work

Do you have implants or prosthetics? Yes No
Removable dental work? Yes No
  • Full uppers
  • Full lowers
  • Partials
  • Partials (lower)
  • Other
Implanted cardiac device? Yes No
Cardiovascular devices:
  • Defibrillator
  • Pacemaker
  • Stent
  • Other
Non-cardiac implants? Yes No
Non-cardiac description/location:
Prosthetics? Yes No


Prophylactic Antibiotics

Do you have a need for prophylactic antibiotics? Yes No

Allergies to Medications

Do you have allergies to any medications? Yes No
Name of Medication Allergic to (1): Reaction to this Medication: (ie: rash, vomiting, etc.)

Name of Medication Allergic to (2): Reaction to this Medication: (ie: rash, vomiting, etc.)

Name of Medication Allergic to (3): Reaction to this Medication: (ie: rash, vomiting, etc.)
Are you allergic to Latex? Yes No
Are you allergic to Iodine? Yes No
Do you have any food allergies?
(ie: eggs, peanuts, etc.)
Yes No
List of food allergies:
Do you have environmental allergies? Yes No
List of environmental allergies:

What medications do you take daily?

Medication Name
How Often (i.e. daily, twice daily, once per week, etc.)
Medication Name
How Often
Medication Name
How Often

+ Add Medication

Alcohol and Tobacco

Do you / have you ever used tobacco? Yes No
Packs Per Day
Date Quit?
Do you use chewing tobacco? Yes No
Date Quit?
Do you drink Alcohol?
Yes No
Types of Alcohol
How Often?
How much?
Have you ever used
street / illicit drugs?
Yes No
Last Use

Do you take the following?

Asprin: Yes No
NSAIDs: Yes No
Blood Thinners: Yes No
Platelet Inhibitor: Yes No
Herbal: Yes No
Do you have any additional comments, questions or concerns?
I hereby certify that, to the best of my knowledge, the provided information is true and accurate.
Nothing found at this website should be construed as medical advice or treatment recommendations by SFGIE. This information is not a substitute for consultation for any symptoms you may have. Note that you should consult your gastroenterologist, colorectal surgeon or family physician for medical advice.
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