Colonoscopy - Medical History Form

Contact Information
xxx-xxx-xxxx
Insurance Information
Do you have secondary insurance coverage?
About the Patient
Sex
ex. 5' 8"
Are you currently non-mobile (wheelchair or bed bound)?
Medical History
Have you had a previous colonoscopy?
Have you had a serious illness?
Indicate the year of the event and your age at the time
Have you ever been hospitalized?
Indicate the year of the event and your age at the time
Have you ever had surgery?
Do you have allergies to any medications?
Gastrointestinal History
Please check if you are experiencing any of the symptoms below
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?
Prescription or over the counter
Surgical History
Have you previously had bariatric surgery?
Please provide original bariatric surgery op report and recent testing
Other Information
Have you ever been a patient at UI Health Care?
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.
Attestation
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