Gastroenterology-Hepatology Endoscopy Procedure Form printable pdf download

Phone: (603) 650-5030

Fax: (603) 650-5225

Gastroenterology and Hepatology

Endoscopy Order (procedure)

Please complete patient information below, or attach patient demographic information before faxing.

Patient’s Name: Last _______________________________________ First ________________________________ MI ______________

DOB: _________________________________ SSN: ___________ - _________ - ___________ MR #: ________________________________

Home #: ______________________________ Work #: _______________________________ Cell #: ________________________________

Referring Provider: _______________________________________________________ Office Phone: _____________________________

Contact Name: ______________________________________________________________ Office Fax: _______________________________

COLONOSCOPY

EGD (UPPER ENDOSCOPY)



Upper abdominal distress/dyspepsia



Screening: 50 yrs or older average age risk

No personal/family hx of polyps or cancer

 50 yr old

 Failure after test/treatment



Should be 10 yrs from last colo, or 4 yrs from last flex sig



Dysphagia / Odynophagia (circle one)



unless mitigating factors per Medicare guidelines



Gastrointestinal bleeding/iron deficiency with

suspected upper GI source

Specific indications:



Barrett’s esophagus surveillance



Personal hx of polyps

Date of last EGD: ______________________________

Type: ______________________________________________

Colonoscopy date: ___________________________________

FLEXIBLE SIGMOIDOSCOPY



Personal hx of colorectal cancer



Screening

Last colonoscopy date: _______________________________



Suspected rectal disease when colonoscopy is not



Personal hx of inflammatory bowel disease

indicated

 Colon cancer surveillance

 Diagnosis



Family hx of colorectal cancer or polyps

ADVANCED PROCEDURE

Relation _________________________ age at dx _________

(To be reviewed by an Advanced Endoscopist prior to

Relation _________________________ age at dx _________

scheduling)



Fecal occult blood positive

Iron deficiency: If colonoscopy does not reveal bleeding



EUS*

source (melena or IDA), do you want an EGD done at the



ERCP*

same time?

*Please include all notes pertaining to

 Yes

 No

diagnosis along with radiology reports and



Hematochezia (rectal bleeding)



Evaluation of abnormality on barium enema or other pertinent

disks.

test: describe: _______________________________________

__________________________________________________



Other, describe: _____________________________________

CODE STATUS*

__________________________________________________



Full Code

PATIENT SAFETY



Limited Resuscitation (e.g. no chest compression

For patient safety reasons, please include the following

but intubation okay)

information on your patient:

Do Not Resuscitate (DNR)



*If a patient is a DNR, they must bring their



List of medications

status information with them to this appointment.



Surgical and medical history



Recent history and physical



Procedure reports as applicable

Ordering physician’s signature (required): _______________________________________________ Date: _________________

One Medical Center Drive | Lebanon, NH 03756 | Tel: (603) 650-5000 |

Rev. 8-16-11

Gastroenterology-Hepatology Endoscopy Procedure Form

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