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Click ‘Get Form’ to open it in the editor.
Begin by filling out the Patient Demographic Information section. Enter your full name, date of birth, and contact details accurately to ensure proper identification.
Proceed to the Insurance Information section. If you have health insurance, provide the necessary details including the insurance carrier and member ID. If not, check the appropriate box.
In the Patient Health Information section, answer all questions regarding allergies, smoking habits, alcohol consumption, and family history of colon cancer. Circle 'YES' or 'NO' as applicable.
Continue with Previous History of Colonoscopies and Abdominal Diseases. Indicate any past procedures and complications experienced during those procedures.
List all medications you are currently taking in the Medications You Currently Take section. This is crucial for your safety during the procedure.
Review your answers carefully before signing the Patient Statement at the end of the form. Ensure all information is complete and accurate.

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What are the factors affecting the quality of preparation for colonoscopy?

Diabetes, chronic constipation, a history of abdominal or pelvic surgery, and recent hospitalization are all risk factors for poor cleansing quality.

What causes poor prep for colonoscopy?

The quality of preparation can be affected by many patient factors, including poor sociodemographic status, presence of comorbidities, certain medications and the timing of colonoscopy. These factors account for approximately 25% of inadequate preparations (1,2,5,6).

What is considered high risk patient for colonoscopy?

Patients are considered at high risk if they have: Personal history of colorectal cancer or certain precancerous polyps. Family history of colorectal cancer or certain precancerous polyps, or genetic syndromes. Radiation exposure.

What does Medicare consider high risk for colonoscopy?

Risk Factors You have inflammatory disease (IBD), such as ulcerative colitis or Crohn disease. A family history of colorectal cancer or polyps in parents, grandparents, siblings, or children. Gene changes (variations) in certain genes (rare)