Patients Name:

Medical Record Number:

Patient Phone Number:

Date of Birth:

Sex: Male Female

Patient Address:

Insurance Provider:

Insurance Number:

Was Prep Given to the Patient:NoYes

Type of Prep:HalfytelyFleet phoshosoda*

*Fleet phoshosoda should not be given to patients with congestive heart failure or renal failure

Colon Cancer Screening

Personal History: Polyp Follow-upPersonal History: Cancer Follow-up Family History:
Average Risk (Patients should check with their insurance provider regarding coverage for this producer)
Other:

Colonoscopy

HematocheziaGuaiac PositiveInflammatory Bowel Disease
Iron Deficiency
Other:

Provide supporting labs:
Hgb/Hct:

Ferritin:

Fe/TIBC:

date:

EGD

Dysphagia GERD Nausea/Vomiting:
Hematemesis Dyspepsia
Other:

Has patient been instructed to stop Coumadin 3-5 days prior to the procedure:
No Yes N/A

Has patient been instructed to stop Heparin 1 day prior to the procedure:
No Yes N/A

Does the patient have:

Instructions: If YES, the patient will be referred for a GI office visit to access the risk for conscious sedation.

Congestive heart failure: Yes No

Renal failure: Yes No

Drug Allergies: Yes No

Endocarditis prophylaxis: Yes No

Recommended for patients with high risk cardiac lesion and EGD w/esophageal dilation or sclerotherapy.

Referring physicians name:

Beeper number:

Office number:

Fax number:

PCP: