Colonoscopy Prep

Will you need interpreter services?

How would you like your prep instructions sent to you? Can select multiple * Email
FollowMyHealth Portal
Mail (must select one other option; prep instructions will only be mailed if form is received >7 business days before procedure is scheduled)

Current Height: * ft. in.

Current Weight: * lbs.

Have you had a colonoscopy before? *

Do you have a family history of colon cancer? *

Do you use an assistive device to walk? *

Do you have history of a seizure disorder? *

Do you have history of kidney disease? *

Do you have a defibrillator? *

Do you have obstructive sleep apnea? *

Do you currently have an abdominal aortic aneurism (AAA)? *

Do you have chronic constipation? Chronic constipation is defined as <3 spontaneous bowel movements per week. *

Do you have any other significant health issues or has anything changed with your health history in the past 6 months?

Is there anything else you want us to know?

Are you currently taking a MAO inhibitor? *

Are you currently taking anticoagulants or antiplatelets? * prasugrel (Effient®)
warfarin (Coumadin®)
clopidogrel (Plavix®)
dabigatran (Pradaxa®)
rivaroxaban (Xarelto®)
apixaban (Eliquis®)
enoxaparin (Lovenox®)
ticagrelor (Brilinta®)
None

What other prescription or over-the-counter medications are you currently on? (List name of medication, dosage and frequency) *

Have you had any surgical procedures done in the past? (List procedure and year)

Please list any known allergies.

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