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Gastroenterology Patient Pre-Admission Questionnaire

The Gastroenterology Patient Pre-Admission Questionnaire is used by our staff to obtain a patient's medical history and list of current medications.

Please provide this information to us two weeks before your examination.

If you have any questions regarding the information you need to provide, please contact us. If you would rather use a paper form, click here.


* = required field

Patient/Procedure Information

Personal Medical History

Medications (including prescription and over-the-counter)

List medication names (as listed on medicine bottle) and dosages below:

Note: Aspirin, Ibuprofen, Nsaids, Plavix, and Coumadin may need to be stopped before your procedure. Follow your doctor’s orders as to when you should stop these medications and any other over the counter supplements (multivitamins, herbal supplements, glucosamine etc.).

GI Centers