GI Scheduling Questionnaire
This form must be filled out completely to be able to book a GI procedure at Boulder Medical Center.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Your Current Height (in inches)
*
Your Current Weight (lbs)
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Carrier
*
Insurance Group Number
Insurance Policy Number
*
Insurance Policy Holder Name
*
Insurance Policy Holder Date of Birth
*
-
Month
-
Day
Year
Date
Insurance Policy Holder Phone Number
*
Please enter a valid phone number.
Insurance Policy Holder Relationship to You
*
Insurance Claim PO Box Address
Street Address
City
State / Province
Postal / Zip Code
Referring Provider
*
Primary Care Provider
*
What procedure are you looking to schedule?
Upper Endoscopy GI Procedure (EGD)
*
No
Yes
Why?
*
When was your last EGD?
*
Where did you get your last EGD done?
*
Lower Endoscopy GI Procedure (Colonoscopy)
*
No
Yes
Why?
*
When was your last colonoscopy?
*
Where did you get your last colonoscopy done?
*
Do you have any prior or current health problems?
Answer the following sections below
Kidney
*
No
Yes
Please describe:
*
Heart
*
No
Yes
Who is your cardiologist?
*
Do you wear a pacemaker
*
No
Yes
Do you wear a AICD?
*
No
Yes
Lung
*
No
Yes
Do you have sleep apnea?
*
No
Yes
Do you use a CPAP machine?
*
No
Yes
Do you use an oxygen machine?
*
No
Yes
Diabetes
*
No
Yes
Anesthesia
*
No
Yes
Please describe:
*
After submitting this form, please call our office at 303-440-3216 to schedule your GI procedure.
Thank You
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