Gastrointestinal Specialists of Georgia, PC

Patient First Name *:

Patient Middle Initial:

Patient Last Name *:

Patient Address *:

Patient City *:

Patient ZIP *:

Email *:

Phone Number *:

Sex *: Male Female

Date of Birth *:

Race / Ethnicity *:

Health Insurance*: Yes No

If Yes, which company?:

Pre-Screening Questions

Are you the patient listed above? *: Yes No

Relationship to Patient:

If no, is the patient 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 of 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 was their age at diagnosis?:

Have you had a positive result from Cologuard or FOBT in the last 6 mos? *: Yes No

Section 1 - Medical Conditions

Are you taking any prescription blood thinners (Warfarin, Plavix, Coumadin, 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 a 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 frequent abdominal pain? *: Yes No

Presently have anemia or low blood count? *: Yes No

Are you diabetic? *: Yes No Pills Insulin

Height *:

Weight *:

Do you have any physical limitations? *: Yes No

Have you had issues with cleaning out for a colonoscopy in the past? *: Yes No Prep:

Have you been diagnosed with sleep apnea? *: Yes No

Do you have Hepatitis B, Hepatitis C, or HIV? *: Yes No

Section 2 - Clinical Clearance

Have you had any significant heart disease, such as congestive heart failure or recent coronary artery disease or have you had heart valve replacement or heart surgery? *: Yes No

If yes, when?:

TIA/stroke in the 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 problems? *: 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's name who manages this condition: