Saint Francis GI Endoscopy Center
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Saturday Screening Colonoscopy

Please fill out this medical history form. If approved, you will be directly scheduled for a screening colonoscopy, without a prior office consultation. All of your information will be sent securely, utilizing secure SSL technology. Your personal information will be safe, secure and kept private.

Name:
Address:
Date Of Birth:
Town:
State:
Zip Code:
Height:
Weight:
Tel:
Cell:
Email:
Social Security Number
Who is your insurance provider?
Secondary Insurance Provider
Group Number
ID Number
Group Number
ID Number
Primary Doctor:
Referring Doctor:

Choose a Doctor

Do you have a preference for one of our participating physicians? If so, choose from below.
Dr. Atta-Mensah
Dr. Gazi
Dr. Josephson
Dr. Stone
Dr. Banerjee
Dr. Goldenberg
Dr. Munsaf
Dr. Van Linda
Dr. Dharan
Dr. Hoffman
Dr. Petruff
Dr. Zaldonis
No Preference
If you do not have a physician preference, you will be assigned to the first available appointment
Have you had a Colonoscopy or Sigmoidoscopy done in the past 10 years? Yes No
If yes, what year was it performed?
Who did the procedure?
Were Polyps/Colon Cancer found? Yes No

Current Symptoms

  • Abdominal Pain
  • Nausea
  • Vomiting
  • Bloody Vomiting
  • Fevers
  • Chills
  • Loss Of Appetite
  • Weight Loss
  • Change in Bowel Habits
  • Diarrhea
  • Constipation
  • Rectal Bleeding
  • Blood in Stool
  • Blood on Toilet Paper
  • Hemorrhoids
  • Anal Pain
  • Black, Tarry Stool
  • Gas/Bloating
  • Heartburn
  • Acid Reflux
  • Belching/Burping
  • Indigestion
  • Lactose Intolerant
  • Swallowing
  • Food Sticking in Esophagus
  • Painful Swallowing
  • Jaundice
  • Abnormal Liver Tests
  • Anemia
  • Stool incontinence
  • None

Past Medical History (Select all that apply)

  • None
  • High Blood Pressue
  • Heart Attack/MI
  • Heart Disease/Stents
  • Elevated Cholesterol
  • Heart Valve Murmur
  • Congestive Heart Failure
  • Atrial Fibrillation
  • Heart Arrhythmia
  • Blood Transfusions
  • Pacemaker/Defibrillator
  • Asthma
  • Lupus
  • Emphysema/COPD
  • Lynch Syndrome
  • Tuberculosis
  • Sleep Apnea
  • Lung Clots
  • Diabetes Mellitus
  • Seizure Disorder
  • Stroke/TIA
  • Alzheimer's Disease
  • Parkinson's Disease
  • Thyroid Disease
  • Bleeding Disorder
  • Kidney Problems
  • Hemophila
  • GERD/Acid Reflux
  • Barrett's Esophagus
  • Hiatal Hernia
  • Stomach/Duodenal Ulcer
  • Celiac Disease
  • Helicobacter Pylori
  • Irritable Bowel (IBS)
  • Crohn's Disease
  • Ulcerative Colitis
  • Pancreatitis
  • Hepatitis
  • Hemodialysis
  • Fatty Liver
  • Diverticulosis
  • Diverticulitis
  • Anemia
  • Depression
  • Anxiety Disorder
  • Bipolar Disorder
  • Schizophrenia
  • Arthritis
  • Osteoporosis
  • Fibromyalgia
  • HIV/AIDS
  • Liver Cirrhosis
Cancer Types(s)
Other

Past Surgical History (Select all that apply)

  • None
  • Coronary bypass
  • Defibrillator (AICD) placement
  • Pacemaker Placement
  • Removal of gallbladder
  • Removal of appendix
  • Hiatal hernia repair
  • Removal of uterus
  • Removal of ovary/ovaries
  • Tubal Ligation
  • C-section
  • Lung surgery
  • Gastric bypass surgery
  • Colon surgery
  • Stomach ulcer surgery
  • Inguinal hernia repair
  • Abdominal hernia repair
  • Prostate surgery
  • Total hip replacement
  • Bladder suspension
  • Rectal prolapse surgery
  • Total knee replacement
  • Thyroid surgery
Other

Allergies to Medicine

Are you allergic to any medication? Yes No
If yes, please name medications & reactions:
Are you allergic to latex? Yes No
Are you allergic to eggs? Yes No
Have you ever had problems with Anesthesia? Yes No
If yes, please explain

Medications

  • Do you take any of these blood thinners?
    Amount And Frequency:
  • Aspirin
  • Coumadin / Warfarin
  • Plavix / Clopidogrel
  • Xarelto / Rivaroxaban
  • Lovenox / Enoxaparin
  • Heparin
  • Arixtra / Fondaparinux
  • Pradaxa / Debigatran
  • Aggrenox / Aspirin-dipyridamole
  • Agrylin / Anagriellide
  • Effient / Prasugrel
  • Ticlopidine
  • Other Blood Thinners? Please identify and provide amount and frequency:
  • Do you take these arthritis medications?
    Amount And Frequency:
  • Ibuprofen, Motrin, Advil
  • Naproxen, Aleve, Naprosyn
  • Other arthritis medications? Please identify and provide amount and frequency:
Please list other medications you are taking
(Include "over the counter" medicine, vitamins and doses)

Social History / Marital Status

Marital Status Single Married Divorced Separated Widowed
# of years of formal education completed
Occupation
Do you / have you ever used tobacco? Yes No
Packs Per Day
Years?
Date Quit?
Do you use chewing tobacco? Yes No
Frequency
Years?
Date Quit?
Do you drink Alcohol?
Yes No
Types of Alcohol
How Often?
How much?
Have you ever used
street / illicit drugs?
Yes No
Type
Last Use

Family History (Select all that apply)

  • Colon polyps
  • Colon Cancer
  • Rectal Cancer
  • Uterine/Cervical cancer
  • Ovarian Cancer
  • Breast Cancer
  • Prostate Cancer
  • Stomach Cancer
  • Small bowel cancer
  • Esophageal cancer
  • Skin Cancer(Melanoma)
  • Liver Cancer
  • Pancreatic Cancer
  • Kidney/Ureter cancer
  • Crohn's Disease
  • Hepatitis
  • Bleeding Problems
  • Ulcerative Colitis
  • Celiac Disease
  • Gallbladder Disease
Other Cancer(s)
How did you hear about us?
  • Primary Care Doctor
  • Direct Mailing
  • Highway Billboard
  • Facility Web Site
  • Other
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.

Click the submit button below to send
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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