Endoscopy Questionnaire
Hutchinson Clinic Endoscopy Department
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= required field
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Patient's Name:
*
First Name
Middle Name
Last Name
Proposed Procedure:
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Colonoscopy
Upper Endoscopy (EGD)
Procedure Date:
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Please select a month
January
February
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December
Month
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Day
Please select a year
2025
2024
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2022
2021
2020
2019
2018
Year
Doctor performing procedure:
*
Dr. Clarke
Dr. Shaw
Dr. Gleason
Dr. Johnson
Dr. Brown
Dr. Ellis
Why are you doing this procedure?:
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Have you ever had this procedure done before?:
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Yes
No
Other
If yes, when, with whom, and what did they find?:
Medication List:
*
Drug Allergies:
*
Weight?:
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Height?:
*
Latex allergy:
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Yes
No
Back
Next
Date Questions Completed:
*
Please select a month
January
February
March
April
May
June
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December
Month
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Day
Please select a year
2021
2020
2019
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2015
Year
TO BE COMPLETED BY THE PATIENT OR FAMILY/SIGNIFICANT OTHER
PERSONAL
HISTORY
1. Do you wear dentures?:
*
Yes
No
2. Do you wear hearing aids?:
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Yes
No
3. Do you have high blood pressure?:
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Yes
No
4. Do you have any heart arrhythmias? Ex: Atrial fibrillation? Atrial flutter? Premature Ventricular Tachycardia?:
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Yes
No
5. Do you have congestive heart failure?:
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Yes
No
6. Have you had a heart attack, stent placement or a stroke in the past 12 months?:
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Yes
No
If yes, when?:
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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31
Day
Please select a year
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2020
2019
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Year
7. Do you have any blood clotting or bleeding disorders?:
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Yes
No
If yes, what?
8. Are you on short term or long term steroid use?:
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Yes
No
If yes, please explain why you take them?
9. Do you have asthma?:
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Yes
No
10. Do you have sleep apnea?:
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Yes
No
If yes, do you use a CPAP at night?:
Yes
No
11. Do you use oxygen at home?:
*
Yes
No
If yes, how much?
12. Do you get short of breath when lying down flat?:
*
Yes
No
13. Have you had a recent upper respiratory infection
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Yes
No
14. Do you have a cough?:
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Yes
No
15. Do you have acid reflux disease?:
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Yes
No
16. Do you have a hiatal hernia?:
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Yes
No
17. Do you have Hepatitis? Cirrhosis?:
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Yes
No
18. Are you a diabetic? Do you take insulin?:
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Yes
No
19. Do you have chronic renal failure?:
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Yes
No
20. Do you have end stage renal disease?:
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Yes
No
21. Do you have any thyroid disease?:
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Yes
No
22. Do you have Epilepsy?:
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Yes
No
23. Do you have Rheumatoid Arthritis?:
*
Yes
No
24. Have you ever had a surgery on your neck or throat?:
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Yes
No
25. Have you ever had radiation to your neck?:
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Yes
No
26. Have you had your gallbladder removed?:
*
Yes
No
27. Have you ever had any joints replaced?:
*
Yes
No
If yes, which ones?:
28. If you are a woman have you had a hysterectomy or tubal ligation?:
Yes
No
29. Do you have an internal defibrillator?:
*
Yes
No
If yes, when was it last interrogated?:
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
30. Do you have a pacemaker?:
*
Yes
No
31. Do you have 1st degree relatives (Mom, Dad, Brothers, Sisters or Kids) with Colon cancer?:
*
Yes
No
32. Do you smoke?:
*
Yes
No
33. Do you drink alcohol?:
*
Yes
No
34 Do you use any recreational drugs?:
*
Yes
No
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