SCHEDULE AN APPOINTMENT

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Please complete the form below in order to schedule your colonoscopy

GASTROINTESTINAL SPECIALISTS OF GEORGIA, PC

Patient first name :*
Patient Middle Name:*
Patient Last Name:*
Patient Address :*
Sex :
MM slash DD slash YYYY
Health Insurance :

PRE-SCREENING QUESTIONS

** IF YES TO ANY OF THE BELOW, REFER TO BENEFITS VERIFICATION
Are you the patient listed above?:
if no, is the patient is disabled/able to give medical consent?:
Have you had a colonoscopy before
Personal history of colorectal cancer?:
Personal History if Polyps?:
Polyp Type:
Family history of colorectal cancer or pre-cancerous polyps in first-degree relative(parent, sibling, child)
If Yes, Which Relative?:
Have you had a positive result from Cologuard or FOBT in the last 6 months?:

SECTION 1 - MEDICAL CONDITIONS

Are you taking any prescription blood thinners(Warfarin, Plavix, Coumadin, OFFICE VISIT: Pradaxa. Effient, Brilinta, Xarelto, Eliquis, Aggrenox or Arixtra)?:
Are you had a heart attack in the last month?:
Do you have Hemophilia/bleeding or blood clotting disorder?:
Are you currently on dialysis?:
Are you on transplant list?:
Are you pregnant?:
Do you have a colostomy bag?:
Do you have frequent bleeding?:
Do you have hidden blood in stool. Hemoccult+?:
Are you having unexplained weight loss?:
Currently experiencing diarrhea, constipation or significant change in bowel habits?:
Have frequient abdomenal pain?:
Presently have anemia or low blood count?:
Are you diabetic?:
Pills / Insuline?:

SECTION 2 - CLINICAL CLEARANCE

Have 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?:
TIA Stroke in last month?:
Seizure in the last 6 months?:
Do you have renal disease?
If yes, are you on either? Hemodialysis or Peritoneal Dialysis:
Do you have COPD or any lung problem?:
Do you have a pacemaker?:
If yes , is it a defibrillator?:
If yes to any question listed on Section 2 , Please include the physician who manages this condition: