GI Procedure Scheduling Questionnaire

GI Scheduling Questionnaire
Date

MonthDayYear
Name*

First NameLast Name
Day Time Phone Number*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Insurance Carrier*
Insurance Group Number*
Insurance Policy #*
Insurance Phone Number
Insurance Claim PO Box Address

PO Box

Street Address Line 2

CityState

Zip Code
Insurance Policy Holder Name*
Insurance Policy Holder's Birth Date*

MonthDayYear
Date
Insurance Policy Holder Relationship to you*
Referring Provider*
PCP *
Date of Birth*

MonthDayYear
Age
Height*
Feet and Inches
Weight*
LBS
Are you a new patient to Boulder Medical Center*

YesNo
Have you had your primary care provider fax your medical history and last physical to (303) 440-3097?

NoYes
Pharmacy Phone Number
Preferred Pharmacy*
What procedure are you looking to schedule?*

Upper Endoscopy GI Procedure(EGD)Lower Endoscopy GI Procedure (Colonoscopy)
Why are you having an EGD?
When was your last EGD?
Where was your last EGD done?

Boulder Medical CenterName of Facility
Have you ever had esophageal varies?
Where was your last colonoscopy done?

Boulder Medical CenterName of Facility
When was your last colonoscopy?
Have you ever had polyps removed or a biopsy done?
DO YOU HAVE ANY OF THE FOLLOWING PROBLEMS? **If you answer YES to any of the questions, you are required to provide us the most recent medical records(s) from your provider before we can schedule your procedure.
Kidney*

YesNo
Do you have ankylosing spondylitis*

YesNo
Please provide details about your kidney issues:
Diabetes*

YesNo
Cardiac*

YesNo
Do you have a pacemaker?

YesNo
Do you wear an ACID?

YesNo
Who is your Cardiologist?
Lung*

YesNo
Do you have sleep apnea?

YesNo
Do you use a CPAP machine?

YesNo
Do you use oxygen?

YesNo
Do you take any medications for diabetes orweight loss:*

YesNo
Please list the diabetes or weight loss drugs you are taking:
Have you had previous problems with Anesthesia?*

YesNo
Please provide details about your anesthesia issues:
Calculation
Should be Empty:

GI Scheduling Questionnaire

DO YOU HAVE ANY OF THE FOLLOWING PROBLEMS? **If you answer YES to any of the questions, you are required to provide us the most recent medical records(s) from your provider before we can schedule your procedure.