GASTROENTEROLOGY PRE-PROCEDURE ASSESSMENT Clinic Location

Please fax completed form to Rita Hoy at (510) 437-5020 or ext. 45020

Screening Colon _____ Urgent Procedure ____

TRANSLATOR REQUIRED: Yes No

PATIENT NAME (PRINT): _________________________________________ Home Phone #:

(Last) (First)

DOB: _____/ _____/_____

PROCEDURE: EDG ____ Colon ____ ERCP ____ PEG ____ Flexible Sigmoidoscopy ____ Other: ________________

INDICATIONS:

MEDICAL ASSESSMENT: DIABETIC: Y / N HIGH BP: Y / N ANTICOAG: Y / N COUMADIN ____ PLAVIX ____

PMH: AGGRENOX

Pacemaker ____ Artificial valve ____

ANESTHESIA HX: ( ) prior Cons. Sedation

( ) no prior anesthetic complications

( ) history of extreme response to sedating medications

DRUG/EOTH USE: drug / alcohol / both / neither / intoxicated

MEDS: ASA ____ NSAIDS ____

OTHERS

ALLERGIES: ( ) NKDA ( ) PCN / Sulfa / Demerol / MS / Codeine / Other: ______________________

PHYSICAL:

AIRWAY: ABD: BP:

HEART: LUNGS: OTHER:

RELEVANT LAB DATA:

ASA CLASS (circle one): 1 – Healthy 2 – Mild Systemic *3 – Severe Systemic 4 – Incapacitating Systemic

TRANSFUSION RISK: ( ) None ( ) High (needs Pt/Ptt/platelet count before procedure)

ANTIBIOTIC PROPHYLAXIS: ( ) None ( ) Other

I have informed the patient regarding the nature of and alternatives to the planned procedure, including the conscious sedation plan, the expected benefits, and the potential risks and complications. __________ (initials)

________________________ ____________________ AM/PM ____________________________________________________________________

DATE TIME SIGNATURE

PHYSICIAN’S PRINTED NAME TELEPHONE #

HISTORY AND PHYSICAL UPDATE:

￡ I have reviewed the pre-procedure assessment and patient is determined to be an appropriate candidate for sedation. No significant change since last History and Physical on _____________________________.

________________________ ____________________ AM/PM ____________________________________________________________________

DATE TIME SIGNATURE

1. All patients on aspirin/non-steroidals/plavix or coumadin must stop medication 5 days before procedure. If substitution Lovenox it must be stopped 12 hours before procedure.

2. Patients with artificial heart valves get antibiotic treatment 1 hour before procedure.

3. Patients should stop oral diabetic medications. If on insulin, take ? dose the day before procedure and none the day of procedure.

4. *3-Severe Systemic patients who are unstable must be seen in GI clinic before a procedure can be done.

GI Form/Bernstein/Adaly