Skip to main content
  • Request An Appointment
  • MyChart
  • Pay a Bill or Get an Estimate
  • For Referring Providers
  • Explore UI Health Care
    • Adult Care
    • Pediatric Care
    • Cancer Center
    • Carver College of Medicine

Main Menu

  • Find a Provider
  • Services
  • Locations
  • Your Visit

More Menu

  • Contact Us
  • About Us
  • COVID-19
  • Clinical Trials
  • Educational Resources & Support Groups
  • News and Stories
  • Share Your Story
  • Health Topics
  • Jobs
  • Medical Records
  • Volunteer
  • Donate
  • Info For... Directory
  • Find a Provider
  • Services
  • Locations
  • Your Visit
  • Request An Appointment
  • MyChart
  • Pay a Bill or Get an Estimate
  • For Referring Providers
  • Explore UI Health Care
    • Adult Care
    • Pediatric Care
    • Cancer Center
    • Carver College of Medicine
  • Contact Us
  • About Us
  • COVID-19
  • Clinical Trials
  • Educational Resources & Support Groups
  • News and Stories
  • Share Your Story
  • Health Topics
  • Jobs
  • Medical Records
  • Volunteer
  • Donate
  • Info For... Directory
  • 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

  1. Home
  2. Gastroenterology
  3. Colonoscopy
  4. Colonoscopy - Medical History Form
Email Colonoscopy - Medical History Form
Share Colonoscopy - Medical History Form on Facebook
Share Colonoscopy - Medical History Form on Twitter
Share Colonoscopy - Medical History Form on LinkedIn
Print Colonoscopy - Medical History Form

Colonoscopy - Medical History Form

Contact Information
xxx-xxx-xxxx
Insurance Information
Do you have secondary insurance coverage?
About the Patient
Sex This field is required.
ex. 5' 8"
Are you currently non-mobile (wheelchair or bed bound)? This field is required.
Medical History
Have you had a previous colonoscopy? This field is required.
Have you had a serious illness? This field is required.
Indicate the year of the event and your age at the time
Have you ever been hospitalized? This field is required.
Indicate the year of the event and your age at the time
Have you ever had surgery? This field is required.
Do you have allergies to any medications? This field is required.
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? This field is required.
Prescription or over the counter
Surgical History
Have you previously had bariatric surgery? This field is required.
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.
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

Sidebar content

  • 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
Clinical Trials currently in progress
Browse all clinical trials in progress

200 Hawkins Drive
Iowa City, IA 52242
United States

1-800-777-8442
  • Request an appointment
  • Directions and parking
  • See all locations
  • Facebook
  • Twitter
  • Youtube
  • Instagram

Patient and Visitors

  • Your visit
  • MyChart
  • Contact us
  • Find a provider
  • Browse medical services
  • Share your story

Medical Professionals

  • Resources for referring providers
  • Refer a patient online
  • Request a consult
  • Clinical trials
  • Educational resources

Employees & Community

  • About us
  • Resources and support groups
  • News and patient stories
  • Health topics
  • Join our team
  • Employee updates
  • Nondiscrimination Notice
  • HIPAA Notice of Privacy Practice
  • Web Privacy Policy
  • Accessibility
  • University of Iowa Indigenous Land Acknowledgement
  • Translation services
  • Financial services
  • Patient Experience Office
  • Guest and Concierge Services
  • Spiritual services
  • Volunteer Services
  • Sitemap
  • cancer.uiowa.edu
  • uihealthcare.org
  • medicine.uiowa.edu
  • medicineiowa.org
Copyright © 2023

The University of Iowa. All Rights Reserved.

University of Iowa Stead Family Children’s Hospital is part of University of Iowa Hospitals & Clinics.