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ABOUT US
- Our History
PHYSICIANS
SERVICES
- Serving The Greater Houston Area With Locations In Southwest Houston, Sugarland, Katy, Memorial City, Downtown, Pearland and Cypress.
- Our Services
RESOURCES
NEWS
LOCATIONS
PATIENT PORTAL

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Colonoscopy Screening Form

Name

Email

DOB

Weight

Height

Allergies

Are you an established patient or new patient?

New Established

Have you ever had a colonoscopy before?

Yes No

Approximate Date

Were Polyps found

Yes No

Do you have a personal history of colon cancer?

Yes No

Do you have a family history of colon cancer?

Yes No

Are you currently under treatment for kidney disease or renal insufficiency?

Yes No

Are you currently under treatment for heart failure, heart valves, pacemaker, or do you have a history of Rheumatic fever, endocarditis, or have any intravascular prostheses (stents, shunts)?

Yes No

Are you currently under treatment for COPD or emphysema?

Yes No

Are you currently on any anti-coagulation or anti-platelet medications? (Plavix, Coumadin, Xarelto, Aspirin) - Blood Thinners

Yes No

Are you on any weight loss medication?

Yes No

Are you pregnant or possibly pregnant?

Yes No

Do you have a history of diverticulitis or inflammatory bowel disease? (Chron's or ulcerative colitis)

Yes No

Do you have a history of TIA (transient Ischemic Attack) or stroke?

Yes No

Do you have a history of any disorder (lung, liver, heart, kidney) requiring oxygen supplementation?

Yes No

Do you have any other medical problems that we have not discussed?

Are you taking medications?

Yes No

Address: PO Box. 2529

Stafford, TX 77497

Phone: 713-772-1200

Fax: 713-255-6315

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Our Services

HERNIA SURGERY
INGUINAL HERNIA
MASTECTOMY
THYROIDECTOMY
COLONOSCOPY
FISSURECTOMY
ADRENALECTOMY

Operating Hours

Monday - Friday08:30 - 5:00

SaturdayCLOSED

SundayCLOSED

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