Barnes-Jewish
West County Hospital

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Endoscopy Patient Questionnaire

Please complete the following form regarding your health history.
If you have any questions, you can call our Endoscopy Department at 314-996-3822.
  

General Information

*
Patient Name
*
Date of Birth
*
Height
*
Weight
*
Date of your upcoming procedure
Last menstrual period (if female):
Check all that apply:
*
Are you allergic to any medications, food, or latex
If yes, please list allergies and reactions below
List of current Medications, including the dosage, and frequency taken

Medical History

Please check all that apply
































Additional Medical History

Do you drink alcohol?
If yes, how much and how often?
*
Do you smoke?
How many pack(s) per day?
Year started smoking
Year quit smoking (Leave blank of you have not quit)

GI History

*
Is this endoscopy for routine screening purposes?
Do you have a history of any of the following:











Additional GI History

*
Do you have any pain?
Describe the pain
Location of pain
Is there a family history of colon problems or colon history?
If yes, explain
*
Have you ever been hospitalized for an infection which required a private room and staff wore yellow gowns?
*
Do you have any implanted electronic devices (pacemaker, defibrillator, etc)?
Please list any implanted devices (such as pacemaker, defibrillator, etc.) that you have.
List any previous surgery
*
Phone
E-mail
Security Code
Type Security Code

Please type the unique security code in the box above.
If you have trouble reading the code, click on the two arrows to get a new code.

After you hit the SUBMIT button below, you will see a confirmation that your form was sent.
You may need to scroll up to the top of your screen to see the message.

If you have any questions about this form or your upcoming endoscopy procedure,
please call our Endoscopy Department at 314-996-3822.