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.)
 

Patient/Procedure Information

(* = Required)
*Patient Name: *Phone:
*Date Of Birth:  Email:
 Weight: lbs.  Height: ft. in.
*PCP Name:  Phone:
 Cardiologist Name:  Phone:
*Date of Procedure:
*Procedure(s):
    Anal Monometry
    Capsule Endoscopy
    Colonoscopy
    Endocinch
    Endoscopy
    Endoscopic Ultrasound
    Enteroscopy
    ERCP
    Motility Testing
Reason for Procedure:
 
Family history of colon, esophageal or gastric cancer?
  Yes  No
If "Yes", who?
 

Personal Medical History
Please check if you have/had any of the following medical conditions/issues:
Alcohol Use Kidney Problems Pregnant Smoker
Diabetes Latex Sensitivity Currently Breast Feeding Stroke
Heart Problems Liver Problems Seizures Valve Replacement
High Blood Pressure Pacemaker/AICD Sleep Apnea
Cancer
     List type(s) of cancer:
    
Breathing Problems
     Breathing Problems explained:
    
Have had Sedation in the past
     If you've had a bad reaction to Sedation, please describe:
      
Describe any Surgeries you've had in the past:
    
Describe any other Medical Conditions you may have:
    

Medications (including prescription and over-the-counter)

List medication names (as listed on medicine bottle) and dosages below:
Name: Dosage:
Name: Dosage:
Name: Dosage:
Name: Dosage:
Name: Dosage:
Name: Dosage:
List any Medication Allergies you have, along with your reaction:
        
 
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:


Enter the code shown above:
 
 
 
 
 
 
 
 
 
 
 
Click here to download a paper formNote: If you would rather print and fill out a paper form, download the form here. Fax or mail your completed form to:
Hartford Hospital
GI Endoscopy
Suite 300
85 Jefferson Street
Hartford, CT 06102
Fax: (860) 545-2785
 
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