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Keyword
In this section
Gastroenterology
Acute and Chronic Liver Disease
Advanced Nutritional Services
Anorectal Disorders
Bariatrics
Celiac Disease
Chronic Intestinal Pseudo-Obstruction
Colonoscopy
Colonoscopy - Medical History Form
Endoscopic Ultrasound
Fructose Intolerance
GI Bleeding
GI Reflux Surgery
Gastroparesis
Heartburn, Reflux, and GERD
Hepatology
Breadcrumb
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Gastroenterology
Colonoscopy
Colonoscopy - Medical History Form
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Colonoscopy - Medical History Form
Contact Information
Full Legal Name
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Address
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City
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State
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- Select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
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New York
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Ohio
Oklahoma
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Pennsylvania
Rhode Island
South Carolina
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Tennessee
Texas
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Vermont
Virginia
Washington
West Virginia
Wisconsin
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Zip
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Daytime Phone
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xxx-xxx-xxxx
Email
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Insurance Information
Insurance Company Name
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Policy or Member Number
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Policy Holder's Name
This field is required.
Policy Holder's Date of Birth
This field is required.
Do you have secondary insurance coverage?
Yes
No
Secondary Insurance Company Name
Secondary Policy or Member Number
Secondary Policy Holder's Name
Secondary Policy Holder's Date of Birth
Secondary Insurance Customer Service Phone Number
About the Patient
Sex
This field is required.
Male
Female
Date of Birth
This field is required.
Height
This field is required.
ex. 5' 8"
Current Weight
This field is required.
Are you currently non-mobile (wheelchair or bed bound)?
This field is required.
Yes
No
Medical History
Diabetes
Never
Current
Past
Heart Disease
Never
Current
Past
Coronary Stent Placement
Never
Current
Past
Heart Failure
Never
Current
Past
Heart Attack
Never
Current
Past
Pacemaker Placement
Never
Current
Past
Home Oxygen Use
Never
Current
Past
High Blood Pressure
Never
Current
Past
Sleep Apnea
Never
Current
Past
Daytime Sleepiness
Never
Current
Past
Snoring
Never
Current
Past
Reflux (Heartburn)
Never
Current
Past
High Cholesterol
Never
Current
Past
High Triglycerides
Never
Current
Past
Joint Pain
Never
Current
Past
Back Pain
Never
Current
Past
Hip Pain
Never
Current
Past
Knee Pain
Never
Current
Ankle and Foot Pain
Never
Current
Past
Swelling of Feet
Never
Current
Past
Urinary Stress Incontinence
Never
Current
Past
Blood Clots
Never
Current
Past
Deep Vein Thrombosis (DVT)
Never
Current
Past
Pulmonary Embolism
Never
Current
Past
Stroke
Never
Current
Past
Shortness of Breath
Never
Current
Past
Asthma
Never
Current
Past
Emphysema
Never
Current
Past
Headaches
Never
Current
Past
Migraines
Never
Current
Past
Kidney Disease
Never
Current
Past
Seizures
Never
Current
Past
Rashes
Never
Current
Past
Arthritis/Osteoarthritis
Never
Current
Past
Cancer
Never
Current
Past
Irregular Periods
Never
Current
Past
Eating Disorder
Never
Current
Past
Non-Alcoholic Fatty Liver or Non-Alcoholic Steatohepatitis
Never
Current
Past
Other (please specify)
Never
Current
Past
Other Medical Issues
Have you had a previous colonoscopy?
This field is required.
Yes
No
When and where did you receive that colonoscopy?
Have you had a serious illness?
This field is required.
Yes
No
Please describe any serious illnesses
Indicate the year of the event and your age at the time
Have you ever been hospitalized?
This field is required.
Yes
No
Why were you hospitalized?
Indicate the year of the event and your age at the time
Have you ever had surgery?
This field is required.
Yes
No
Indicate the year, type of surgery, and whether it was laparoscopic
Do you have allergies to any medications?
This field is required.
Yes
No
Please describe your allergies
Gastrointestinal History
Please check if you are experiencing any of the symptoms below
Heartburn
Bloating
Difficulty Swallowing
Abdominal Pain
Food Getting Stuck
Get Full Quickly
Pain With Swallowing
Belching
Nausea/Vomiting
Hiccups
Choking
Fever
Weight Loss
Weight Gain
Bowel Habit Changes
Diarrhea
Constipation
Rectal Bleeding
Black Stools
Jaundice
Rectal Pain
Fatigue
Other…
Other(Explain)
Note: If an patient is experiencing any of the above symptoms, he or she will be scheduled for a pre-screening consult visit in our GI Clinic prior to procedure.
Medications
Do you routinely take medications?
This field is required.
Yes
No
Prescription or over the counter
Please list current medications and dosages
Surgical History
Have you previously had bariatric surgery?
This field is required.
Yes
No
Please explain where, when, the type of procedure, and reason for seeking a revision
Please provide original bariatric surgery op report and recent testing
Other Information
Have you ever been a patient at UI Hospitals & Clinics?
This field is required.
Yes
No
Preferred contact method
Email
Phone
At the University of Iowa we treat all health information as personal and confidential. Health information will only be given to a patient in person or via direct phone contact unless the patient gives express permission to provide Protected Health Information in another way. Please indicate your preference for receiving health information to the following questions.
I may be contacted on my cell phone
A message can be left on my cell phone voice mail
Protected Health Information can be left on my voice mail at home
Protected Health Information may be sent to me via my home email
I can be contacted at my work phone number
Protected Health Information may be left on my voicemail at work
Protected Health Information may be sent to my work emailI would like a copy of my Protected Health Information sent to my Family Physician
I would like a copy of my Protected Health Information sent to my Family Physician
Attestation
I understand the importance of providing accurate information and have completed this form to the best of my ability.
This field is required.
Leave this field blank
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