Booking Questionnaire

Please complete the form below to submit your Booking Questionnaire. You can also download the PDF form.

Upper Endoscopy and Colonoscopy Questionnaire

Name

Height

Weight

Do you take Blood Thinners?

If yes, name of medication (if yes, refer to list and inform pt of # days to hold medication)

Do you take Iron Supplements? (double/colon only)

if yes, inform to hold x 5 days prior to the appt

Do you have any Cardiac issues? (ie: heart attack, heart surgery, pacemaker/ICD, A-fib)

Notes

Do you have Sleep Apnea?

If yes, do you use a CPAP machine?

Do you have Diabetes?

Bring your glucometer to your appointment (if applicable).

Do you suffer with constipation on a regular basis?

if yes, follow 2x2L preparation instructions

Do you take Ozempic for ANY reason?

if yes, hold x 2 weeks prior to the appointment

Do you take Wegovy or Saxenda for ANY reason?

if yes, x 2 week prior to the appointment

Please wear a t-shirt or tank top to your appointment.

Additional notes

If you are human, leave this field blank.

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