Colonoscopy Preparation Instructions (Prepopik) Patient Name: ___________________________________ Date of Procedure: ________________

7 Days Prior to Your Colonoscopy

- You must be off Aspirin/NSAIDS and other blood thinners (Coumadin/Warfarin, Lovenox, Plavix, Xarelto, Eliquis) 7 days prior to the procedure. Tylenol is ok to take.

- Please have the prescription for Prepopik Bowel Prep Kit filled at your pharmacy.

1 Day Prior to Your Colonoscopy

Have a light breakfast (one boiled or poached egg; white toast-no butter, plain bagel). Do NOT eat vegetables, fruits, nuts, seeds, butter, milk, cheese, beef, pork, lamb, or whole grain cereals.

Clear liquid diet after breakfast. No solid food.

• You may drink clear liquids such as apple juice, cranberry juice, Gatorade, clear broth, tea, coffee, soda, popsicles, and Jello-O (avoid any red or sugar free Jell-O due to artificial dyes)

• Do not have any milk products, citrus juice, or solid food

• Make sure to drink plenty of water throughout the day

• Diabetics: Take only half of your diabetes medication the day prior to your procedure

Step 1: 6 PM (Day prior to colonoscopy)

• Fill the Prepopik dosing cup with cold water up to the lower (5 ounce) line on the cup

• Pour in ONE packet and stir for 2-3 minutes until dissolved

• Drink all liquid in the container

• Follow by drinking at least 40 ounces (five glasses) of another clear liquid of your choice over the next 4 hours

Step 2: Perform 6-8 hours prior to the time of your colonoscopy (ex: if your colonoscopy is scheduled at 10AM the following day, perform this step at 4AM on the day of your colonoscopy)

• Repeat the same regimen found in Step 1

Remember:

• You may take your regular medications at your regular time with a tiny sip of water except blood thinners or aspirin

• Vaseline or Desitin are good skin protectants to be applied prior to starting prep

Day of Colonoscopy:

• 4 hours before: stop drinking all liquids including water. Your procedure may be cancelled if this is not followed.

Arrive at: ______________________________________ Check-in Time: ___________________

Please be advised that your check in time is tentative. You will be called the business day prior to your procedure to confirm the time. You must have someone drive you home following the colonoscopy due to the medications given. Uber/Lyft/Taxi are NOT acceptable.

963 N McQueen Rd Chandler, AZ 85225 ph: (480) 646-8440 fax: (480) 646-8441

BLOOD THINNERS!!

!

Prescription Products Non-Prescription Products!

Anticoagulants!• Arixtra!• Coumadin!• Eliquis!• Lovenox!• Pradaxa!• Warfarin!• Xarelto

Containing Ibuprofen!• Advil !• Bayer!• Ibuprofen!• Midol!• Motrin

Containing Aspirin or Aspirin Like Products!• Aggrastat!• Aggrenox!• Agrylin!• Brilinta!• Celebrex!• Darvon!• Dipyridamole!• Effient!• Fiorinal Caps/Tabs!• Fiorinal w/ Codein Caps/Tabs!• Indocin!• Lortab ASA Tablets!• Percodan !• Plavix !• Pletal!• Robaxisal Tablets!• Soma !• Talwin !• Ticlid!• Trilisate Tabs/Liq!• Vioxx

Containing Aspirin or Asprin-Like Products!• Anacin!• Arthritis Pian Formula Tablets!• Bayer!• Bufferin!• Ecotrin!• Excedrin!• Midol!• Mobigesic!• Trigesic

Containing Ibuprofen:!• Children’s Advil!• Children’s Motrin!• Motrin

Containing Naproxen Sodium!• Anaprox!• Naproxen

963 N McQueen Rd Chandler, AZ 85225 ph: (480) 646-8440 fax: (480) 646-8441

Patient Registration FormPatient Information

Name (First / Middle Initial / Last): Date of Birth:

Marital Status: Single Married Divorced Widowed Separated Other:

Address: City: State: Zip:

Primary Phone: Secondary Phone:

Email: Gender: Social Security #:

Referring Physician: Primary Care Physician:

Preferred Language: Race: White Black or African American Asian

American Indian/Alaska Native Native Hawaiian/Other Pacific Islander Uknown Patient Declines to Specify

Ethnicity: Hispanic or Latino Not Hispanic or Latino Patient Declines to Specify

Responsible Party:

Name: Address:

State: Zip: Phone:

(This person will be contacted in the case of an emergency ONLY)

Relationship: Phone:

Additional Information

Occupation: Employer:

Insurance Information

Primary Insurance Company: Relationship to Subscriber: ID #:

Group #: Network: Claims Address:

Subscriber Name: Birth Date: Subscriber Social Security #:

Secondary Insurance Company: Relationship to Subscriber: ID #:

Group #: Network: Claims Address:

Subscriber Name: Birth Date: Subscriber Social Security #:

Pharmacy Information

Name: Phone:

Cross Streets: Address:

I assign all medical/surgical benefits to Arizona Center for Digestive Health, P.L.L.C. and understand that I am financially responsible for all charges whether or not they are paid by insurance. I authorize payment to be made to the provider. In the event that the payment is made to the policyholder, I agree to submit payment in full to this office immediately. I hereby authorize the doctor to release or procure all information necessary to secure the payments of benefits, for treatment purposes, or to another health care provider or destination at my discretion. I may revoke this authorization at any time in writing, with the exception of insurance disclosures for billing purposes. I consent to communicate via electronic means for routine matters. I further agree that a photocopy of this agreement shall be as valid as the original. I certify the above information is true and correct to the best of my knowledge. I understand that HIPAA and privacy policies are available online and in the office by request.

I have read and understand the information on this form. I confirm that the information I have provided here is correct and true to the best of my knowledge.

Signature: Date:

Self KƚŚĞƌ�

City:

Emergency Contact

Name:

Patient Interview FormPatient Information

First Name: Last Name: DOB: Today’s Date:

Email Address:

Reminder Preference Would you like to receive preventative care and follow up reminders? Yes No

Allergies

Patient has no known allergies Patient has no known drug allergies Latex Penicillins Demerol Fentanyl Versed

Iodine Propofol Sulfa Eggs Other:

Past or Present Medical Conditions

Patient has no known medical conditions

NEUROLOGY ENDOCRINE CARDIAC Stroke Thyroid Disorder Heart Attack

Seizures/Epilepsy Diabetes High Blood Pressure

Dementia Osteoperosis Atrial Fibrillation

Parkinson’s Elevated Cholesterol Congestive Heart Failure

LUNGS URINARY RHEUMATOLOGY

Asthma Enlarged Prostate Fibromyalgia

COPD Prostate Cancer Lupus

Valley Fever Kidney Stones Rheumatoid Arthritis

Sleep Apnea Kidney Cancer

PSYCHIATRIC CIRCULATION BLOOD

Anxiety Disorder Deep Vein Thrombosis Anemia

Depression Carotid Artery Disease Leukemia

Bipolar Disorder Pulmonary Embolus Lymphoma

Schizophrenia Peripheral Vascular Disease Bleeding Disorder

GASTROINTESTINAL Cirrhosis Colon Cancer

Colon Polyps Irritable Bowel Syndrome H. pylori

Diverticulosis Stomach Ulcer Lactose Intolerance

Pancreatitis Ulcerative Colitis Crohn’s Disease

Barrett’s Esophagus Hepatitis B Celiac Sprue

GERD Hepatitis C

CANCER Type:

CONDITIONS NOT LISTED:

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Patient Interview FormFirst Name: Last Name: DOB: Today’s Date:

Diagnostic Studies/Tests

None

Colonoscopy Upper Endoscopy ERCP EUS

When: When: When: When:

Ultrasound CT Scan MRI Liver biopsy Recent labs

When: When: When: When: When:

Previous Procedures & Surgeries

None

Cataract surgery Tonsillectomy Heart valve Pacemaker

Defibrillator Appendectomy Carotid artery Abdominal aneurysm

C-section Hysterectomy Breast surgery Prostate surgery

Joint surgery Bowel surgery

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,ĞŵŽƌƌŚŽŝĚƐ Coronary bypass Coronary artery stent

Other:

Social History

Occupation: Number of Children:

Marital Status

Single Married Divorced Separated Widowed

Civil Union Other:

Alcohol

None Quantity Number Frequency

Beer

Wine

Hard Liquor

Tobacco/Smoking Status

Current, Every Day Smoker Current, Some Day Smoker Former Smoker

Smoker, Status Unknown Unknown if ever smoked Never Smoked

Drug Use

None Quantity Number Frequency

IV Drugs

Other:

Patient Interview FormFirst Name: Last Name: DOB: Today’s Date:

Mother Father Sister Brother Daughter Son Grandmother Grandfather Aunt Uncle

Colon cancer

Colon polyps

Celiac disease

Ulcerative colitis

Crohn’s disease

Liver disease

No knowledge of family history

No family history of: Colon Cancer Polyps

Current Medications

Patient has no known medications

Name Dose How Taken?

Consent to Import Medication History

I consent to Arizona Center for Digestive Health obtaining a history of my medications purchased at pharmacies.

Yes No

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Patient Interview FormFirst Name: Last Name: DOB: Today’s Date:

Review of Systems (Please Select All Recent Symptoms)

Yes No Yes No

CARDIOVASCULAR GENITOURINARY

Chest pain Dark urine

Shortness of breath with exercise Painful urination

Palpitations Blood in urine

CONSTITUTIONAL INTEGUMENTARY

Loss of appetite Yellowing of the skin

Weight gain Rash

Weight loss Tattoos

Piercings

ENMT

Sore throat MUSCULOSKELETAL

Nose bleeds Arthritis

Hoarseness Back pain

ENDOCRINE NEUROLOGICAL

Excessive thirst Dizziness

Hair loss Frequent headaches

Heat intolerance Numbness or tingling

GASTROINTESTINAL PSYCHIATRIC

Abdominal pain Anxiety

Abdominal bloating Depression

Constipation

Diarrhea RESPIRATORY

Difficulty swallowing Cough

Gas Coughing up blood

Heartburn Wheezing

Nausea

Rectal bleeding

Vomiting

Reviewed with

Patient Parent Guardian Not Present

HIP�A Privacy Acknowledgment

x I have received the HIP�A Privacy Notice regarding the uses and disclosures of my Protected Health Information�and I understand my rights and responsibilities with respect to my medical records.

x I hereby authorize Arizona Center for Digestive Health͕�W>>� to release any medical or incidental information to my�referring physician or any other physicians who have been or may become involved in my care.

x I also authorize the release of information that may be necessary in the processing of any insurance claims.x I also authorize the release of any medical records including pharmacy records to Arizona Center for Digestive�

Health͕�W>>� upon request.

PERSONAL REPRESENTATIVES

(Family members, attorneys, etc.): I hereby authorize Arizona Center for Digestive Health͕�W>>� and its Employees permission to discuss, send and/or receive medical information to/with the following individuals:

Name: Relationship to patient:

Name: Relationship to patient:

Name: Relationship to patient:

Decline (I do not authorize permission to discuss, send and/or receive medical information to/with others.)

FAXES

When expedient, I authorize the transmittal of my records by FAX. I understand that transmission by FAX, but its very nature, is not confidential.

MESSAGES

It is OK to leave a message on my home phone voice mail #: Yes No

It is OK to leave a message on my cell phone voice mail #: Yes No

It is OK to leave a message on my work phone voice mail #: Yes No

Patient Name (Please Print): Date of Birth:

Patient Signature: Date: