Last Updated: 11/14 Form: PP-PHS-01

Physician: Phone Number: Patient Name: Location:

Date of Procedure: Time to Arrive: Date of Removal: Time to Arrive:

Pre-Procedure Instructions for 24 Hour pH Study – Off Meds Welcome to the MGH GI Manometry Unit. We would like to make your stay as pleasant and safe as possible. Please read these instructions carefully before your pH study. Please plan to spend about 1 hour in our unit for your procedure. We will do everything possible to avoid a delay in your procedure, but emergencies may interrupt the schedule. BEFORE you start to prepare for your procedure:

Call your insurance company for an insurance referral, if required. Update your MGH registration information at 1-866-211-6588, if you have not done so within 6 months.

If you are on any medications used to control stomach acid, please refer to this list of instructions:

1. ONE WEEK before the procedure, please stop proton pump inhibitors. These include omeprazole, Prilosec, lansoprazole, Prevacid, esomeprazole, Nexium, rabeprazole, Aciphex, pantoprazole, Protonix.

2. THREE DAYS before the procedure please stop H2 blockers. These include Tagamet, cimetidine, ranitidine, Zantac, Pepcid, famotidine, nizatidine, Axid.

3. TWO DAYS before the procedure please stop promotility drugs. These include Reglan, metoclopramide, Cisapride, propulsid.

4. 6 HOURS before the procedure stop all antacids. ON THE DAY of your procedure:

1. Do not eat or drink anything for 6 hours before the procedure. 2. If you take insulin, we recommend that you take ½ your usual dose. 3. You may take all your usual medicines with a small amount of water. 4. Wear an open collar shirt. 5. Please bring your completed Patient Medication List to the procedure.

AFTER your procedure:

1. You will receive diet and medication instructions after your procedure. 2. You may return to work after the procedure, although you will have a thin tube in your nose taped to your

cheek for the 24-hour period. If you have questions about your procedure, call the Patient Information Line at (617) 726-0388 and leave a message. A registered nurse will return your call.

ESOPHAGEAL MANOMETRY, pHz AND pH PHYSICIAN ASSESSMENT FORM

Name:_______________________________________________________________

Date of Birth: / / Age:______________

Physician:__________________________ Referring Physician:__________________________

Reason for Test:________________________________________________________________

When was the last time you had something to drink?___________________________________

When was the last time you had something to eat?_____________________________________

1. Do you have trouble swallowing? � YES � NO (If the answer is NO skip to question 5)

2. How long have you had trouble swallowing?________________________________________

3. If you have trouble swallowing please answer the following questions:

How did the problem start? � SUDDENLY � GRADUALLY OVER TIME

How often does it happen? � ALL THE TIME � SOMETIMES � RARELY

With solids? � YES � NO With liquids? � YES � NO

4. How would you describe your problem (check)?

� I have trouble when I start to swallow, getting the food to leave my mouth.

� Food gets stuck after it leaves my mouth.

5. Do you have pain when you swallow? � YES � NO

6. Do you cough while eating? � YES � NO

7. Do liquids ever come back up into your nose while you are eating? � YES � NO

8. Please check the answer that applies to you for each of the following:

Chest Pain: � NEVER � DAILY � WEEKLY � MONTHLY � OTHER______________

Heartburn: � NEVER � DAILY � WEEKLY � MONTHLY � OTHER______________

Antacid Use: � NEVER � DAILY � WEEKLY � MONTHLY � OTHER______________

Cough: � NEVER � DAILY � WEEKLY � MONTHLY � OTHER______________

(PLEASE TURN OVER)

PATIENT STICKER

PHYSIC

IAN F

ILE

Last Updated: 4/14Form: PMF-01

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Please check if you have a history of any of the following medical problems:

� Breathing problems

� Heart disease

� High blood pressure

� Bleeding disorders

� Strictures, fistulas, or obstructions in your gastrointestinal system

� Esophageal tumors, ulcers, or varices

� Deviated septum

� Nasal obstruction

� Hiatal hernia

Please check if you have you had any of the following?

� Gastric surgery When________________________

� Esophageal dilation When___________________________

� Barium x-ray When_______________________________

� Previous endoscopies When_________________________

Please list any additional medical problems that you have:

Please list any surgeries that you have had:

Patient’s Signature:______________________________________________________________

Reviewed By:_______________________________________Date:_____________Time:_________

PATIENT STICKER

PHYSIC

IAN F

ILE

Last Updated: 4/14Form: PMF-01

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MOTILITY PATIENT HOME MEDICATION FORM (PLEASE ONLY COMPLETE THIS SIDE OF FORM)

Please list any medication allergies that you have:

Do you have an allergy to latex? � YES � NO

Please list all of your medications (include those that you stopped prior to this test): MEDICATION NAME DOSE FREQUENCY LAST TAKEN

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

Please sign below:

Patient Signature: __________________________________________________________________

Reviewed by Nurses Signature: ____________________________________Date: ____/_____/___ Time:_______

PATIENT STICKER O

RIG

INA

L PUT IN

RN

FILE

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PHYSIC

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FILE

Last Updated: 4/14Form: PMF-01

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Last Updated: 8/14Form: DD-01

Parking Information & Directions

☐ Blake Building, 4th Floor – 55 Fruit Street, Boston, MA

Parking: Fruit Street Garage –or– Parkman Street Garage Garages are located off of Cambridge Street

Directions from the garage: After parking in the Fruit Street -or- Parkman Street Garage

Enter through the Main entrance

Take the E elevator to the 4th floor of the Blake Building

Once you exit the elevator, look for the glass door labeled GI Associates

☐ Charles River Plaza, 9th Floor – 165 Cambridge Street, Boston, MA

Parking: Our Charles River location has two options for parking:

1. Charles River Plaza Parking Garage, 207 Cambridge Street – this is the preferred parking location2. Fruit Street Garage -or- Parkman Street Garage

Directions from the garage:

From the Charles River Plaza Parking Garage (Preferred Parking Location)

Look for the Orange wall labeled 165 CambridgeStreet

Take the elevator to the 9th floor

The entrance will be on your left

From the Fruit Street / Parkman Street Garages

Walk down North Grove Street, take a left ontoCambridge Street

After walking 2 ½ blocks, you will see the sign forCharles River Plaza on your left

The 165 Cambridge St. building will be on theright of the plaza - enter through the glass doors

Elevators are at the end of the hallway, go to the9th floor - the entrance will be on your left

☐ Mass General / North Shore, 102-104 Endicott Street, Danvers, MA

Parking: Center for Outpatient Care parking lot

Directions from the garage: Enter through the Main Entrance

Elevators will be straight ahead

For Procedures: Take the elevators to the 2nd floor

For Office Visits: Take the elevators to the 3rd floor

Please visit the MGH Parking Office website for more information and directions to our locations: www.massgeneral.org/visit

Last Updated: 8/14 Form: DD-01

Parking Information & Directions

☐ Blake Building, 4th Floor – 55 Fruit Street, Boston, MA

Parking: Fruit Street Garage –or– Parkman Street Garage Garages are located off of Cambridge Street

Directions from the garage: After parking in the Fruit Street -or- Parkman Street Garage

Enter through the Main entrance

Take the E elevator to the 4th floor of the Blake Building

Once you exit the elevator, look for the glass door labeled GI Associates

☐ Charles River Plaza, 9th Floor – 165 Cambridge Street, Boston, MA

Parking: Our Charles River location has two options for parking:

1. Charles River Plaza Parking Garage, 207 Cambridge Street – this is the preferred parking location 2. Fruit Street Garage -or- Parkman Street Garage

Directions from the garage:

From the Charles River Plaza Parking Garage (Preferred Parking Location)

Look for the Orange wall labeled 165 Cambridge Street

Take the elevator to the 9th floor

The entrance will be on your left

From the Fruit Street / Parkman Street Garages

Walk down North Grove Street, take a left onto Cambridge Street

After walking 2 ½ blocks, you will see the sign for Charles River Plaza on your left

The 165 Cambridge St. building will be on the right of the plaza - enter through the glass doors

Elevators are at the end of the hallway, go to the 9th floor - the entrance will be on your left

☐ Mass General / North Shore, 102-104 Endicott Street, Danvers, MA

Parking: Center for Outpatient Care parking lot

Directions from the garage: Enter through the Main Entrance

Elevators will be straight ahead

For Procedures: Take the elevators to the 2nd floor

For Office Visits: Take the elevators to the 3rd floor

Please visit the MGH Parking Office website for more information and directions to our locations: www.massgeneral.org/visit