Self-Referral Colonoscopy Questionnaire

A colonoscopy is recommend to screen for colorectal cancer when 45 years or older.

Name

Date of Birth

Age

Gender

Weight

Height

Phone number

Email address

Address

Insurance name

Insurance policy number

Are you 45 years of age or older? Yes No

Do you have any personal history of colorectal cancer or polyps? Yes No

Do you have a family history of colon or colorectal cancer in a parent, brother, sister, or child? Yes No

Do you have any chronic health problems? Yes No

If you answered "yes" to having chronic health problems, please note them below.

Please list all previous surgeries.

Do you take any medications? These include prescribed medications, all herbals, vitamins, weight-loss medications, and over-the-counter medications. Yes No

Please list all prescription medications, over-the-counter medications, vitamins, herbal supplements, blood thinners, or GLP-1 (weight loss or diabetes) medications.

Do you have any of these symptoms? Select all that apply.

If you have these symptoms, you may need to see a provider before the colonoscopy.

Frequent Diarrhea Constipation Abdominal Discomfort Rectal Bleeding None of the Above

Which of the following do you currently use? Select all that apply. Marijuana Tobacco Alcohol Other recreational drugs None of the above

Do you have a pacemaker or implanted defibrillator (ICD)? Yes No

Have you ever had a problem with anesthesia or sedation during a procedure or surgery? Yes No

Please sign your name below, giving the Digestive Health staff permission to review any records within RVMC pertaining to this referral.