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Yamini Maddala, M.D.
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Direct Schedule Screening Colonoscopy Referral Form
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Allen
McKinney
Prosper
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Home
Symptoms
Acid-Reflux
Abdominal Pain
Constipation
Diarrhea
Difficulty-Swallowing
Gas and Bloating Pain
Hemorrhoids
Heartburn
Anal/Rectal Bleeding
Procedures
Endoscopy
Colonoscopy
Open Access Colonoscopy
Capsule Endoscopy
Hemorrhoid Banding
Endoscopic Retrograde Cholangio Pancreatography (ERCP)
Liver-Biopsies
Digestive Conditions
Colon/Colorectal Cancer
Celiac Disease
Crohn’s Disease
Fatty-Liver
Irritable Bowel Syndrome (IBS)
Impact of Pregnancy
Hepatitis A, B & C
Pancreatitis
Ulcers
Ulcerative Colitis
Providers
Direct Schedule Screening Colonoscopy Referral Form
Patient Information
New Patient Forms and Patient Portal
Approved Insurance Providers
Colonoscopy Questionnaire
Procedure Preparation Forms
Directions to Endoscopy Centers
Hospital Privileges / Affiliations
Telemedicine
Appointments
Directions
Allen
McKinney
Prosper
Colonoscopy Questionaire
Home
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Colonoscopy Questionaire
Colonoscopy Questionaire
user
2020-11-10T14:04:12-06:00
Yamini Maddala, M.D.,
Deepti Dhavaleshwar, M.D.,
Phone:
469.697.5100
Web Site
Date
*
Date
Physician
*
Yamini Maddala, M.D
Deepti Dhavaleshwar, M.D
Type
New Patient
Follow Up
Referring Physician
*
Patient Name
*
DOB
*
Sex
*
Male
Female
Transgender
Email Address
*
Cell Number
*
Home Number
Address
*
City
*
State
*
Zip
*
Name of Health Plan
*
Insured DOB
*
Insurance ID
*
Group Plan ID
*
Pharmacy
Pharmacy Phone/Location
Have you had a Colonoscopy in the past?
*
Yes
No
If yes, When
If yes, Where
Results
*
Normal
Polyps
Cancer
Other
Other
Weight
*
Height:
Feet
*
Inches
*
BMI
Medication Details (Name, Dose, How Often)
Allergies
Do you have a history of Myocardial Infarction (Heart Attack)
*
Yes
No
Unstable Angina/Heart Failure//Aortic Stenosis/Stents?
*
Yes
No
Are you taking any blood thinners, other than baby aspirin?
*
Yes
No
Do you have any breathing problems/lung disease? (COPD, Emphysema)
*
Yes
No
Are you on continuous or supplemental oxygen?
*
Yes
No
Are you on dialysis or diagnosed with kidney disease?
*
Yes
No
Any chance you could be pregnant?
*
Yes
No
Do have high blood pressure? If yes, is it controlled with medication?
*
Yes
No
Do you have a history of seizures?
*
Yes
No
Are you diabetic?
*
Yes
No
If diabetic
Type I
Type II
Other
Other
Do you take prescription narcotics, anti-depressants, sleep aids, anxiety medication?
*
Yes
No
Do you have sleep apnea?
*
Yes
No
Do you use a CPAP?
*
Yes
No
Do you have any bleeding or circulatory disorders?
*
Yes
No
Stroke, Blood Clots, Other:
Have you ever been diagnosed with cancer?
*
Yes
No
If yes, what type:
Have you had any problem with anesthesia?
*
Yes
No
If yes, details:
Have you had an organ transplant other than cornea?
*
Yes
No
If yes, what type:
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