The Gastroenterology Patient Pre-Admission Questionnaire is used by our staff to obtain a patient's medical history and list of current medications.
Please provide this information to us two weeks before your examination.
(If you have any questions regarding the information you need to provide, please contact us
. If you would rather use a paper form, click here
(* = Required)
Personal Medical History
Please check if you have/had any of the following medical conditions/issues:
Medications (including prescription and over-the-counter)
Note: Aspirin, Ibuprofen, Nsaids, Plavix, and Coumadin may need to be stopped before your procedure. Follow your doctor’s orders as to when you should stop these medications and any other over the counter supplements (multivitamins, herbal supplements, glucosamine etc.).
|Use this space to tell us anything else you need to about your medical condition:
Note: If you would rather print and fill out a paper form, download the form here
. Fax or mail your completed form to:
85 Jefferson Street
Hartford, CT 06102
Fax: (860) 545-2785