Pre-procedure Questionnaire - Digestive Health Partners

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Please Select a Location*

Name*

First Middle Initial Last

Sex at Birth*

Gender You Identify As

SSN

(We ask for SSN to help verify benefits for Medicare and Medicare Advantage plans)

Date of Birth*

Race

Ethnicity

Marital Status*

Please enter your marital status*

Address*

Street Address Address Line 2 City State ZIP Code

Mobile Phone Number*

Work Phone

Email*

Preferred Language*

Please enter your preferred language.*

HIPAA Contact Information

Is there anyone you give us permission to speak with about your health information?*

Yes

Contact Name*

First Last

Relationship to patient*

Because you picked other, please list your relationship to the contact person.*

Phone*

Primary Care Provider Name*

Primary Care Provider Location*

Insurance Information

Do you have insurance?*

Yes

Primary Insurance Information

Primary Health Insurance Company*

Example: Blue Cross Blue Shield, Humana, etc.

Medicare?*

Yes

Name Displayed on Card*

First Last

Policy ID*

Group ID*

Plan ID

Policy Holder's Name*

First Last

Relationship to Patient*

Policy Holder's Date of Birth*

Policy Holder's Employer*

Do you have Secondary (Supplemental) Insurance?*

Yes

Secondary Insurance Information

Secondary Health Insurance Company*

Medicare?*

Yes

Name Displayed on Card*

First Last

Policy ID*

Group ID*

Plan ID

Policy Holder's Name*

First Last

Relationship to Patient*

Policy Holder's Date of Birth*

Policy Holder's Employer*

Height (Feet)*

Please enter a number from 1 to 7.

Height (Inches)*

Please enter a number from 0 to 11.

Weight (lb.)*

This field is hidden when viewing the form

BMI

Are you currently pregnant?*

Yes

Do you take any blood thinners?*

Yes

What is the name of your blood thinner and managing provider?*

For example: wrfarin/coumadin, Plavix/clopidogrel, lovenox/enoxaparin, Xarelto/rivaroxaban, Eliquis/apixaban

Do you have a Cardiac Defibrillator?*

Yes

Do you use continuous oxygen?*

Yes

How many liters do you use per day?*

Pharmacy Information

What pharmacy do you use?*

In the event we need to prescribe a medication, please enter your preferred pharmacy name.

Pharmacy Address*

Street Address Address Line 2 City State ZIP Code

We will obtain your medication list from your pharmacy to keep your records up to date. Please check here if you DO NOT want to participate.

DO NOT obtain my medication list from my pharmacy.

By checking this box, you do not grant DHP permission to receive your medication list from your pharmacy.

Medical Information

Are you taking Dofetilide (Tikosyn)?*

Yes

Has anesthesia given you a letter about a difficult airway or have a history of difficult intubation?*

Yes

Please explain what difficulties you were having.*

Do you take weight loss medication?*

Yes

What weight loss medication(s) do you currently take?*

Do you experience chest pain or shortness of breath when walking up a flight of stairs?*

Yes

In last 6 months, any symptoms or newly diagnosed issues for your heart and/or lungs?*

Yes

Do you have any further workup planned?*

Do you have an Abdominal Aortic Aneurysm?*

Yes

Is your AAA >5cm?*

Yes

Have you had an evaluation for your AAA in the last 12 months?*

Yes

Do you have severe aortic stenosis?*

Yes

Do you have idiopathic thrombocytopenia, platelet clotting disorder, or any other blood disorder?*

Yes

Have you had or are planning to have a heart, lung, or kidney transplant?*

Yes

Do you have decreased kidney function?*

Yes

Are you on dialysis or have you been told you will need dialysis?*

Yes

Do you have diabetes?*

Yes

Do you take insulin or other diabetes medications?*

Yes

Have you had any major surgeries in the last 3 months, including abdominal or gastrointestinal related?*

Yes

Do you have a seizure disorder?*

Yes

When was your last seizure?*

Have you had any major health changes, hospitalizations, or ER visits in the last 6 months?*

Yes

Please explain more about your major health changes in the last six months.*

Have you had any head or neck surgeries/injuries that restrict your range of motion?*

Yes

Have you ever had radiation to your head or neck area?*

Yes

Are you currently on chemotherapy?*

Yes

Do you have a port for IV or blood access?*

Yes

Do you require an ultrasound to find IV access?*

Yes

Have you been treated for C.Diff in the past and currently having symptoms?*

Yes

Have you had or are you being treated for diverticulitis within the last six weeks?*

Yes

Do you have any mobility issues we should be aware of?*

Yes

Please describe your mobility issues:*

Do you have any health issues we have not discussed that may interfere with your procedure?*

Yes

Please provide details about your other health issues:*

Do you have Narcolepsy?*

Yes

Do you have Spasmodic Dysphonia?*

Yes

Do you have Addison's Disease?*

Yes

Do you have Autonomic Dysreflexia?*

Yes

In the last 30 days, have you used heroin, cocaine or methamphetamines?*

Yes

How often do you use tobacco/nicotine products?*

How frequently do you use alcohol?*

Do you have any allergies to medications?*

Yes

Allergies*

Please list your allergies.

Medication

Reaction

Do you take any prescription medications?*

Yes

Medications*

Please list your medications.

Medication

Dose

Frequency

Route (oral, injection, etc.)

Do you use a wheelchair/walker?*

We'll be prepared for you on your visit if you do.

Yes

GI Related Conditions*

None

Achalasia

Barrett's Esophagus

Colon Cancer

Colon Polyps

Diverticulitis of Colon

Diverticulitis

Endometriosis

Eosinophilic Esophagitis

Esophageal Cancer

Esophagitis

Gallstones

Gastric / Duodenal Ulcer

Gastritis

GERD (Gastroesophageal Reflux)

H-Pylori

Hemorrhoids

Hiatal Hernia

Inflammatory Bowel Disease (Crohn's / Ulcerative Colotis)

Irritable Bowel Syndrome (IBS)

Lynch Syndrome

Pancreatitis

Stomach Cancer

Heart & Lung Conditions*

None

Asthma

Atrial Fibillation

Congestive Heart Failure

COPD / Enphysema

Coronary Artery Disease

Heart Valve Disease

Heart Attack (Myocardial Infarction)

High Blood Pressure

High Cholesterol / Lipids

Lung Cancer

Pulmonary Hypertension

Stroke (Creebrovascular Accident)

Sleep Apnea

TIA / Mini Stroke (Transient Ischemic Attack)

Do you have Tuberculosis?*

Yes

Are you currently being followed by a neurologist, cardiologist, vascular, or lung disease specialist?*

Yes

Please list the name of the practice and provider you see.*

Practice Name

Provider Name

Liver Conditions*

None

Cirrhosis

Hepatitis A

Hepatitis B

Hepatitis C, Chronic

Elevated Liver Function Test

Liver Cancer

Non-Alcoholic Fatty Liver Disease

Kidney Conditions*

None

Adrenal Insufficiency

Diabetes Mellitus (Type I)

Diabetes Mellitus (Type II)

Kidney Dialysis

Kidney Failure

Blood, Nervous System, and Auto-Immune Conditions*

None

Anemia

Arthritis

Bleeding Disorder, Prolonged Bleeding

Blood Transfusion

Celiac Sprue

Hemochromatosis

HIV / AIDS

Hyperthyroidism

Hypothyroidism

Iron Deficiency Anemia

Leukemia, Chronic

Lymphoma, Unspecified

Multiple Sclerosis

Peripheral Vascular Disease

Thrombocytopenia (Low Platelets)

Tuberculosis

Other Cancer Related Conditions*

None

Brain Tumor

Breast Cancer

Gynecologic / Ovarian / Cervical Cancer

Prostate Cancer

Radiation Therapy

Skin Cancer

Other Common Conditions*

None

Anxiety Disorder

Depression

Do you have a family history of any of the following?*

None

Breast Cancer

Celiac Disease

Colon Cancer

Colon Polyps

IBD (Crohn's or Ulcerative Colitis)

Esophageal Cancer

Familial Multiple Polyposis Syndrome

Lynch syndrome

Liver Disease

Pancreatic Cancer

Breast Cancer*

Please select each family member that has the condition.

Mother

Father

Sister

Brother

Daughter

Son

Celiac Disease*

Please select each family member that has the condition.

Mother

Father

Sister

Brother

Daughter

Son

Colon Cancer*

Please select each family member that has the condition.

Mother

Father

Sister

Brother

Daughter

Son

Colon Polyps*

Please select each family member that has the condition.

Mother

Father

Sister

Brother

Daughter

Son

IBD (Crohn's or Ulcerative Colitis)*

Please select each family member that has the condition.

Mother

Father

Sister

Brother

Daughter

Son

Esophageal Cancer*

Please select each family member that has the condition.

Mother

Father

Sister

Brother

Daughter

Son

Familial Multiple Polyposis Syndrome*

Please select each family member that has the condition.

Mother

Father

Sister

Brother

Daughter

Son

Lynch Syndrome*

Please select each family member that has the condition.

Mother

Father

Sister

Brother

Daughter

Son

Liver Disease*

Please select each family member that has the condition.

Mother

Father

Sister

Brother

Daughter

Son

Pancreatic Cancer*

Please select each family member that has the condition.

Mother

Father

Sister

Brother

Daughter

Son