Language
English (US)
Español
Colonoscopy Pre-Procedure Intake Form
Please provide your health history to the best of your abilities. Your surgeon will review your responses. Your Protected Health Information is secure on this intake form. If you do not have your procedure date yet, please contact the office at 707-938-7690. Thank you! Dr Alexis and Dr Kidd
Personal Information
Contact Info, Demographics, Emergency Contacts
Name
*
First Name
Middle Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
*
Female
Male
Non-Binary
Trans Male
Trans Female
Other, please describe
E-mail
*
example@example.com
Phone Number
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address, if different from home address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Employer
Insurance Information
*
Plan Name **We will need a copy of the front and back of your card(s). Please upload a legible picture below or email a snapshot of your card to OFFICE@dralexissurgery.com. You may also enter the plan ID number below. **
ID number
Group Number
Effective Date
Medical Group Name, if applicable
Secondary Insurance Information
Supplemental Plan Name. **Please be specific**
ID number
Group Number
Effective Date
Additional information from your insurance card:
Please include any additional information from your card here.
You can upload photos of your insurance cards here. Please include FRONT and BACK.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Or, you can take a photo of the FRONT of your insurance card here.
And, you can take a photo of the BACK of your insurance card here.
Emergency Contact Name
*
First Name
Last Name
Relationship
Emergency Contact Phone Number
Primary Care Physician
First Name
Last Name
Pharmacy
Where can the doctor leave you a detailed message regarding results?
*
Phone, as listed above
E-mail, as listed above
Neither
Other, list here
Your Health Information
Past Medical and Surgical History
Body Measurements:
*
Have you had a COLONOSCOPY before?
*
Yes
No
What YEAR was the most recent colonoscopy performed?
What were the MAJOR FINDINGS on the most recent colonoscopy?
*
Normal colonoscopy
No findings, because this will be the first colonoscopy
Adenomatous polyp (e.g tubular adenoma)
Sessile serrated adenoma
Tubulovillous adenoma
Villous adenoma
Colon Cancer
Hyperplastic polyp
Diverticulosis
Colitis
Microscopic or Collagenous Colitis
Hemorrhoids
Anal Fissure
Poor or incomplete prep
Difficult colonoscopy, tortuous colon, long colon
Other
Have you had any of the following?
A positive result from a FIT test
A positive result from a COLOGUARD test
Family history of colon cancer in a first degree relative
Family history of adenomatous colon polyps in a first degree relative
Bright red blood on stool or with wiping more than a few occasions
Dark blood mixed with stool
Anal pain or itching
Hemorrhoids
Unexplained weight loss
Change in bowel habits: new persistent diarrhea
Change in bowel habits: new persistent constipation
Change in size or caliber for stools ("narrow poops")
Abdominal pain
Colon Cancer
Rectal Cancer
Other
Please list any ALLERGIES; enter "None" if no known allergies.
Have you ever or are you currently being treated for:
*
Any other medical conditions?
Please list your Current Medications, including DOSAGE (how much) and FREQUENCY (how often). If none, list NONE. (Click "+" to add additional medications.)
*
Please list OPERATIONS or major procedures, with approximate DATE. (Please click "+" to add additional operations.)
Women, are you?
Pre-menopausal
Peri-menopausal
Post-menopausal, natural
Post-menopausal, surgical
Other
Age at Menarche (first period)
Age at Menopause
Number of Pregnancies
Number of Births
Age at First Birth
Your Health Habits
Social History
Do you use Alcohol?
*
Please Select
No
Yes
If yes, how many drinks per WEEK
Do you use Tobacco?
*
Please Select
No, never
No, quit more than 1 year ago
No, quit within the last year
Yes, currently I use tobacco
If yes, how many cigarettes (or equivalent) per DAY
Do you use Marijuana?
Please Select
No, never
Yes, daily
Yes, weekly
Rarely, or less than once a month
Additional Comments
Your Family Medical History
Has anyone in your family had cancer or a precancerous condition? Please provide age at diagnosis or other information in the text box below.
Mother
Maternal Grandparent
Father
Paternal Grandparent
Sibling
Breast Cancer
Ovarian Cancer
Colorectal Cancer
Colorectal Polyps
Pancreatic Cancer
Endometrial or Uterine Cancer
Other Cancer (please describe below)
What other diseases run in your family?
Click here if family history is UNKNOWN
Unknown family history
Review of Systems
Please check if you a CURRENTLY having trouble with any of the following: (Check all that apply)
General
Weight loss
Fever/Chills
Fatigue/Malaise
Other
Eyes
Vision changes
Discharge
Eye pain
Other
Ears, Nose, Throat
Earache
Hearing loss
Nosebleeds
Sore Throat
Other
Heart, Vascular
Chest pain
Palpitations
Fainting
Painful breathing with exercise
Pain in legs with exercise
Swelling of arms/legs
Other
Respiratory
Cough
Trouble breathing
Spitting up blood
Wheezing
Other
Gastrointestinal
Nausea or Vomiting
Trouble swallowing, food getting "stuck"
Diarrhea, more than 6 loose stools per day
Constipation
Blood in the stool, red
Black stools
Yellow skin, jaundice
Change in bowel habits
Other
Genitourinary
Painful urination
Blood in the urine
Abnormal menstrual bleeding
Incontinence
Pelvic pain
Other
Musculoskeletal
Back pain
Joint pain
Joint swelling
Muscle weakness
Other
Skin
Rash
Excessive dryness
Suspicious lesion
Other
Neurologic
Paralysis
Numbness
Vertigo
Passing out
Seizure
Other
Psychiatric
Depression
Anxiety
Memory loss
Suicidal ideation
Other
Endocrine
Heat or cold intolerance
Weight loss
Excessive thrist, hunger
Lethargy
Other
Heme/Lymphatic
Abnormal bruising or bleeding
Enlarged lymph nodes
Blood clots
Other
Allergy/Immunologic
Itching
Hay fever
HIV exposure
Persistent infections
Other
If you are OVER 65 years old, have you established an ADVANCE CARE PLAN and/or identified a Surrogate Decision Maker?
Please Select
No, I have not.
No, I have not but will discuss with my primary care physician.
Yes, I have an Advanced Directive (or equivalent) on file at my home.
Yes, I have an Advanced Directive (or equivalent) at my primary care physician's office and/or the Hospital.
Advance directives are designed to respect patient’s autonomy and determine their wishes about future life-sustaining medical treatment if they become unable to indicate their wishes. Advanced Care Planning includes Advanced Directives, Living Wills, POLST Forms, naming a health care proxy or Durable Power of Attorney for Health care, etc.
Thank you! Now, here is the fine print...
Please take a moment to review the policies below and indicate your acceptance. You do not need to print these forms. Your e-signature below indicates that you have READ the policies and ACCEPT the terms, including our "No-show"/cancellation FEES and billing/collections POLICIES. ***Ensure all items with a red asterisk are completed to submit your intake form.***
e-Signature
*
Today's Date
*
/
Month
/
Day
Year
Date
Submit My Colonoscopy Intake Form
Should be Empty: