Patient Procedure Screening

Personal

Patient Name*

Date of Birth*

Email*

Phone*

Ambulatory

Does patient need assistance to walk?*

Yes
No

Does someone other than the patient provide medical consent for them?*

Yes
No

Clinical

Weight (lbs)*

Height (ft)*

Height (in)*

BMI

Age*

Please enter a number from 1 to 120.

Is the patient a diabetic?*

Yes
No

Does the patient use a port to receive medication?*

Yes
No

Does the patient have an automatic defibrillator?*

Yes
No

Has the patient had a heart valve replacement?*

Yes
No

Is the patient on prescribed blood thinners and being seen at request of referral or recall for Dysphagia or Polypectomy?*

Yes
No

Is the patient having an upper scope (EGD) for cirrhosis/varices or banding?*

Yes
No

Does the patient use a rescue inhaler to help them breathe?*

Yes
No

Does the patient use a CPap machine with a setting of 13 or higher?*

Yes
No

Does the patient use a Bipap machine with a setting greater than 8?*

Yes
No

Does the patient take continuous oxygen at home?*

Yes
No

Has the patient been told, during prior procedures or surgeries that they have a restricted airway airway or difficulty being incubated?*

Yes
No

Is the patient on dialysis?*

Yes
No

Has the patient had a diagnosis of diverticulitis (not diverticulosis) in the last 8 weeks?*

Yes
No

Has the patient had a recent diagnosis/or treatment of C. Diff (Clostridium difficile) in the last 8 weeks?*

Yes
No

Is the patient allergic to both Demerol and Fentanyl (allergy includes itching or airway issues)?*

Yes
No

Has the patient ever been told that it takes a lot of medicine to sedate you?*

Yes
No

Does the patient take Pain Medications, Chronic Narcotics, MAO inhibitors, Suboxone (generic buprenorphine), Methadone (other names Methadose, and Dolophine), or have a history of IV (intravenous) drug use?*

Yes
No

Is the patient taking medication for the prevention or treatment of HIV?*

Yes
No

Is the patient's insurance provided by OhioHealth, Mount Carmel or OSU?*

Yes
No

Sign Language Interpreter or Language Translator

Does the patient require a language interpreter/translator?*

Yes
No

Does the patient require a Sign Language Interpreter?*

Yes
No

Email

This field is for validation purposes and should be left unchanged.

Personal

Ambulatory

Clinical

Sign Language Interpreter or Language Translator

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