Get the free PRE-ENDOSCOPY HISTORY FORM - GI Medicine

ENDOSCOPY HISTORY FORM First Name:Last Name:DOB:Age:Height:Weight:Address:City:Home Phone:Cell Phone:Email:Pharmacy Name/Phone Number:Referring Physician:Referring Physician Number:Primary Insurance:Subscriber

How to fill out pre-endoscopy history form

How to fill out pre-endoscopy history form

1. Start by gathering all the necessary information about the patient, including their full name, date of birth, and contact details.
2. Obtain the patient's medical history, including any previous endoscopies they may have undergone.
3. Ask the patient about any allergies they have, particularly to medications or substances used during the endoscopy procedure.
4. Inquire about the patient's current medications, including prescribed medications, over-the-counter drugs, and herbal supplements.
5. Document any pre-existing medical conditions the patient may have, such as heart disease, diabetes, or gastrointestinal disorders.
6. Record any symptoms the patient is experiencing that prompted the need for the endoscopy procedure.
7. Obtain the patient's surgical history, including any past surgeries or procedures related to the gastrointestinal system.
8. Inquire about the patient's lifestyle factors, such as smoking or alcohol consumption.
9. Ensure the form is filled out accurately and legibly, and double-check for any missing information before submitting it.

Who needs pre-endoscopy history form?

1. Anyone who is scheduled to undergo an endoscopy procedure needs to fill out the pre-endoscopy history form. This form helps the healthcare providers gather important information about the patient's medical history, allergies, current medications, and pre-existing conditions. It also allows them to assess any potential risks or complications associated with the procedure. Filling out the form ensures that the healthcare team can provide appropriate care and take necessary precautions during the endoscopy.

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