Pre-exam interview
Exam* SelectUpper EndoscopyColonoscopyUpper Endoscopy and ConoloscopyRectosigmoidoscopyMucosectomy
Anesthesia* [radio* anesthesia use_label_element default:2 "Yes" "No"]
Exam date and time, if scheduled
MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
ㅤㅤ
Hour07:0008:0009:0010:0011:0012:0013:0014:0015:0016:0017:0018:0019:00
Full name*
Insurance*
E-mail
Phone (numbers only)*
Age
Weight (kg)
Height (cm)
Allergies We do not perform tests on patients who are allergic to latex.
Exam indication PreventiveWeight lossDiarrhea or MucusBlood in stoolAnemiaPain or BloatingFamily historyPositive occult bloodConstipation
Other
Previous exams EndoscopyColonoscopy
Year of last exam
Family history of diseases NoYesFather or MotherGrandparentsSiblingsUncles/Aunts
Previous diseases HypertensionHepatitisAsthmaDefibrillatorDepressionCOPDDiabetesBronchitisPacemakerParkinson'sAnemiaNeurological disorderAnxietySmokingStrokeArrhythmiasHIVChronic coughThyroid disorderHeart attack/StentChronic kidney disease
Previous surgeries HysterectomyHerniaColectomyBariatricAbdominoplastyAppendectomyC-sectionCholecystectomy (gallbladder)
Controlled medications AtenololFluoxetinePropranololCaptoprilMetforminClopidogrelLosartanClenilPantoprazoleValproic AcidImipramineAmiodaroneGlibenclamideLevothyroxineEscitalopramOmeprazoleHCTZStatins for cholesterolEnalaprilLorazepamBerotecInsulinAlbuterolGlifageAspirinLisinopril
Do you use anticoagulants? Which one? Check with your doctor about the possibility of stopping the medication.
Other medications
Do you use pens or weight loss medication? YesNo
Does the bowel work well? How many times per week?
Other information
Guardian's name
Relationship
Yes, I agree with the privacy policy
