Please complete the form below in order to schedule your colonoscopy GASTROINTESTINAL SPECIALISTS OF GEORGIA, PCPatient first name :* First Patient Middle Name:* Middle Patient Last Name:* Last Patient Contact Number:*Patient Address :* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Patient Email :* Sex : Male Female Date of Birth :* MM slash DD slash YYYY Race /Ethnicity :*African AmericanAmerican IndianAmerican Indian or Alaska NativeAsianAsian IndianBlackDeclined to SpecifyNative Hawalian or Other Pacific InslanderOther RaceWhiteHealth Insurance : Yes No If Yes, which company?: PRE-SCREENING QUESTIONS** IF YES TO ANY OF THE BELOW, REFER TO BENEFITS VERIFICATIONAre you the patient listed above?: Yes No Relationship to Patient* if no, is the patient is disabled/able to give medical consent?: Yes No Have you had a colonoscopy before Yes No If yes, where / when? Personal history of colorectal cancer?: Yes No Year Diagnosed: Personal History if Polyps?: Yes No Polyp Type: Unknown Adenoma Hyperplastic Family history of colorectal cancer or pre-cancerous polyps in first-degree relative(parent, sibling, child) Polyp Cancer No If Yes, Which Relative?: Parent Sibling Child What is their age?: Have you had a positive result from Cologuard or FOBT in the last 6 months?: Yes No SECTION 1 - MEDICAL CONDITIONSAre you taking any prescription blood thinners (Warfarin, Plavix, Coumadin, OFFICE VISIT: Pradaxa. Effient, Brilinta, Xarelto, Eliquis, Aggrenox or Arixtra)?: Yes No Have you had a heart attack in the last month?: Yes No Do you have Hemophilia/bleeding or blood clotting disorder?: Yes No Are you currently on dialysis?: Yes No Are you on transplant list?: Yes No Are you pregnant?: Yes No Do you have a colostomy bag?: Yes No Do you have frequent bleeding?: Yes No Do you have hidden blood in stool. Hemoccult+?: Yes No Are you having unexplained weight loss?: Yes No Currently experiencing diarrhea, constipation or significant change in bowel habits?: Yes No Have frequient abdomenal pain?: Yes No Presently have anemia or low blood count?: Yes No Are you diabetic?: Yes No Pills / Insuline?: Pills Insuline Height* Weight* SECTION 2 - CLINICAL CLEARANCEHave you had any significant heart disease, such as congestive hear failure or recent coronary artery disease or have you had heart valve replacement or heart surgery?: Yes No If Yes, when?: TIA Stroke in last month?: Yes No Seizure in the last 6 months?: Yes No Do you have renal disease? Yes No If yes, are you on either? Hemodialysis or Peritoneal Dialysis: Hemodialysis Peritoneal Dialysis Do you have COPD or any lung problem?: Yes No Do you have a pacemaker?: Yes No If yes , is it a defibrillator?: Yes No If yes to any question listed on Section 2 , Please include the physician who manages this condition:MD NAME:
