"*" indicates required fields Step 1 of 4 25% HiddenDate MM slash DD slash YYYY Name* First Middle Initial Last Social Security Number*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920*Patient SSN and DOB are needed to collect payment for healthcare services and to verify your identity when requesting and looking up health records.Are you under 45 years old?* Yes No Sex at Birth* Male Female Gender you Identify as* **American Cancer Society recommends screenings at age 45. Please check your screening benefits to verify coverage.Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Race*Please Make a SelectionWhiteHispanicAsianAmerican IndianAlaska NativeBlack or African AmericanNative HawaiianPacific IslanderOtherEthnicity*Please Make a SelectionHispanic Or LatinoNot Hispanic or LatinoDeclinesMilitary*Please Make a SelectionYesNoMarital Status*Please Make a SelectionMarriedSingleDivorcedWidowEmployer* Work Phone Mobile Phone* Home Phone Email* Preferred Language* Primary Care Provider Name* Primary Care Provider Location Primary Care Provider Phone NumberPlease acknowledge that you have read and understood the below information:*As a Medical Office, we are required to provide all patients access to our Patient Portal and an electronic means to contact our office. I understand that I will be sent an email invitation to the Patient Portal and a text message invitation to download a HIPAA compliant texting application, pMD. I understand that I can use both of these options to conversate with the office. I understand HiddenWould you like to sign up for our patient portal using the email address provided above?**The Patient Portal at Digestive Health Partners allows you to communicate with our practice anytime using the internet. You can now pre-register, review your medical history, request appointments, send messages and review clinical results. Yes No Emergency Contact InformationName* First Last Phone*Relationship to Patient* Primary Insurance CoverageWill you be using our self-pay option?* Yes No Note: Self Pay patients will need to speak to a Financial Counselor prior to scheduling an appointment/procedure. Once form is completed, a Financial Counselor will contact you to discuss payment options.Primary Insurance Name* Medicare?* Yes No Name Displayed on Card* Plan ID* Group ID* Policy ID* Policy Holder Name* Policy Holders Relationship* Self, Spouse, Parent, OtherPolicy Holder Date of Birth* MM slash DD slash YYYY Policy Holders Employer* Secondary Insurance CoverageSecondary Insurance Name Medicare?* Yes No Name Displayed on Card Plan ID Group ID Policy ID Policy Holders Name Policy Holders Relationship Self, Spouse, Parent, OtherPolicy Holders Date of Birth MM slash DD slash YYYY Policy Holders Employer Tertiary Insurance Coverage (as needed)ListTertiary Insurance NameName Displayed on CardPlan IDGroup IDPolicy IDPolicy Holders NamePolicy Holders RelationshipPolicy Holders Date of BirthPolicy Holders Employer Add Remove Pre-Procedure Questionnaire**Height AND Weight MUST BE accurate. Patient BMI determines the most appropriate location for procedures. Procedures will be canceled upon arrival if BMI does not meet procedure center guidelines.Height - Feet*Please enter a number from 1 to 7.Height - Inches*Please enter a number from 0 to 11.Weight - Lbs*BMI - Filled Automatically Are you prescribed blood thinner medication?*For example: Warfarin/Coumadin, Plavix/Clopidogrel, Lovenox/Enoxaparin, Xarelto/Rivaroxaban, Eliquis/Apixaban (This does not include Aspirin.) Yes No If you are currently prescribed a blood thinner, please provide the drug name below:*** Our office must obtain authorization from the prescribing provider to safely hold any blood thinner. Once, we obtain the authorization we can proceed to schedule your procedure. Sometimes, the prescribing office will charge a fee which is the patient’s responsibility.**Are you currently taking any of the newer weight loss medications such as: Ozempic, Rybelsus, Trulicity, Victoza, Invokana, Jardiance?* Yes No Please provide the Provider name and phone number of the Provider who prescribes and manages this medication:*Are you currently pregnant?* Yes No Have you delivered a baby in the last 6 months?* Yes No Are you currently breastfeeding?* Yes No Ever had any serious complications with anestheia, besides discomfort or nausea?* Yes No Have you ever been told by an Anesthesiologist that you have a difficult airway, or have had any intubation difficulties in the past?* Yes No Have you been given a letter by an Anesthesiologist stating you have a difficult airway?* Yes No Have you ever had a colonoscopy before?* Yes No Have you ever had any polyps removed?* Yes No With any previous procedure, did you have any significant problems?* Yes No If yes, please give location and date of last colonoscopy.* If yes, please list problems with previous procedures.* Are you diabetic?* Yes No Do you have any symptomatic, severe, uncontrolled heart, lung, or neurological disorders?*Examples would include recent heart surgery, stent placement in the last year, heart attacks in the last 6 months, recent chest pain, uncontrolled COPD, symptomatic congestive heart failure, Stroke, TIA or having sleep apnea requiring continuous oxygen of 2 liters or more. Yes No If yes, what was your last A1C reading?* What do your typical blood sugars run?* Are you insulin dependent?* Do you have a Cardiac Defibrillator?* Yes No Do you have an Abdominal Aortic Aneurysm greater than 4.0?* Yes No Have you had head or neck surgery since you were last seen at our office?* Yes No Are you currently being followed by a Neurologist/Cardiologist/Vascular/Lung Specialist?* Yes No If yes, please provide name and address of Physician.* Are you able to move your head up and down freely?* Yes No Are you able to move your head from side to side freely?* Yes No Do you use prescribed Oxygen 2 liters or more at a time?* Yes No Have you ever had any abdominal or GI Related Surgeries?* Yes No If yes, please list any abdominal or GI Related Surgeries.* Do you have any decreased kidney function?* Yes No Are you currently receiving Dialysis?* Yes No Are you on the Kidney Transplant list?* Yes No Have you ever had a heart and /or lung transplant?* Yes No Do you have narcolepsy?* Yes No Do you have a communicable disease such as TB or active infections?* Yes No If yes, do you take the medication Xyrem (Sodium Oxybate)?* Yes No Have you ever had a seizure?* Yes No Do you currently take any medications for seizures?* Yes No If yes, please list date of last seizure.* If yes, have you had a grand mal seizure in the last 6 months?* Yes No If yes, are they unstable or poorly controlled?* Yes No Have you tested positive for COVID-19?* Yes No Have you received the COVID-19 vaccine?* Yes No Date tested positive.*Please note you may not have procedure within 14 days of testing positive for COVID- 19 MM slash DD slash YYYY If yes, which vaccine did you receive and date of last dose.* Have you received the Flu vaccine?* Yes No If yes, when did you last receive this vaccine?* Have you recently had a fever, respiratory symptoms, cough, or shortness of breath?* Yes No Have you been treated for C-Diff and are now experiencing diarrhea?* Yes No Have you been diagnosed with diverticulitis and placed on antibiotics in the last 6 weeks?***After scheduling, if you are diagnosed with diverticulitis you will need to inform the office. Colonoscopy needs to be delayed approximately 6 weeks and/or an office visit may be needed. ** Yes No Are you currently receiving Chemotherapy?* Yes No Do you have a port for IV or blood draw access?* Yes No Have you, on multiple occasions, required an Ultrasound to find your veins to place an IV or to have blood drawn?* Yes No Do you have an allergy to latex, or anaphylactic reactions?* Yes No Can you walk independently?* Yes No Do you ever require a wheelchair or a walker?* Yes No Can you weight bear and transfer yourself to a stretcher?* Yes No Do you use public transportation for appointments, such as Mtn Mobility?* Yes No Will you have a driver who can bring you to the procedure, stay with you for the duration, and then drive you home? This is required for all Endoscopy Procedures* Yes No Do you have your driver information available now?* Yes No Driver Acknowledgment* I acknowledge that I am required to have a driver the day of my procedure If you can't arrange for a driver, you can utilize the following approved transportation services here.Driver's Name* First Last Relationship* Mobile Phone*Can you take care of yourself (eating, dressing, bathing, or using the toilet)?* Yes No Can you walk a block or two on level ground?* Yes No Can you climb a flight of stairs or walk up a hill?* Yes No Can you run a short distance?* Yes No Can you do light work around the house like dusting or washing dishes?* Yes No Can you do moderate work around the house like vacuuming, sweeping floors, or carrying in groceries?* Yes No PhoneThis field is for validation purposes and should be left unchanged.