Colonoscopy Questionaire

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

Weight

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

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:

Yamini Maddala, M.D., Deepti Dhavaleshwar, M.D., Phone: 469.697.5100

Yamini Maddala, M.D.,
Deepti Dhavaleshwar, M.D.,
Phone: 469.697.5100