GI Clinic OUR CLINIC REQUIRES 72 HOUR NOTICE FOR CANCELLATION DUE TO THE TIME WE ALLOW FOR YOUR APPOINTMENT

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GI Clinic OUR CLINIC REQUIRES 72 HOUR NOTICE FOR CANCELLATION DUE TO THE TIME WE ALLOW FOR YOUR APPOINTMENT

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GI Clinic OUR CLINIC REQUIRES 72 HOUR NOTICE FOR CANCELLATION DUE TO THE TIME WE ALLOW FOR YOUR APPOINTMENT You are scheduled with: Appointment Date: Arrival Time: Please complete the enclosed questionnaire along with the medication list. Bring ALL paperwork with you to your appointment, picture ID and your insurance card. Report to the Surgery Waiting Room to register for your procedure. You will be sedated for this procedure. You will need someone to drive you home and stay with you following your procedure for 24 hours. No mode of public transportation will be allowed, including taxis, buses or walking alone. Please have your driver with you at check-in to verify your ride. If having a colonoscopy or flexible sigmoidoscopy, you will need to purchase a bowel prep. See enclosed information. Helpful Hints: Remain at home and close to the bathroom after beginning the prep. If you develop nausea or vomiting while drinking the prep solution, take slower sips. Sometimes chilling the liquid and drinking through a straw will help. If you have any questions, call the GI Clinic at 816-887-0457 between 8:00 a.m. and 3:00 p.m., Monday thru Friday.

Flexible Sigmoidoscopy Prep OUR OFFICE REQUIRES 72 HOURS NOTICE FOR CANCELLATION DUE TO THE TIME WE ALLOW FOR YOUR APPOINTMENT If you have any questions, call our office at 816-887-0457 between 8:00 a.m. and 3:00 p.m., Monday thru Friday. You have been scheduled for a Flexible Sigmoidoscopy Please arrive at: You will need to purchase 4 Fleets Enema s Your Prep Instructions are as Follows: 1. If you take any blood thinners, please call the GI department (816-887-0457) to determine whether to stop this medication and the time frame to hold. Blood thinners include, but are not limited to the following; Coumadin, Warfarin, Xarelto, Eliquis, Savaysa, Pradaxa, Dipyridomole, Aggrenox, Pletal, Plavix, Ticlopidine, or Effient. If you take Insulin, please check with your doctor that prescribes this for you about adjusting your dose prior to your test. TAKE NO INSULIN OR ORAL DIABECTIC MEDICATIONS THE MORNING OF YOUR TEST. Stop all Diet Pills including over the counter, herbal and prescription 7 days prior to your procedure, this includes Phentermine, Qsymia, ect 2. Give yourself 2 Fleets Enema s the evening BEFORE the procedure. 3. The day before the procedure there are no diet restrictions. 4. DO NOT HAVE ANYTHING FURTHER TO DRINK AFTER MIDNIGHT. If your procedure is at 1:00 p.m. or later, you can drink 6 ounces of water up to 4 hours prior to the procedure. 5. Give yourself 2 more Fleets Enema s 1 hour prior to your arrival time. 6. Please take your scheduled/prescribed medications for heart problems, asthma, pain, anxiety, high blood pressure, breathing problems and seizures, unless otherwise instructed by your physician. Drink only enough water to swallow your pill(s)- no more than 4 fluid ounces. 7. You will be sedated for this procedure. YOU WILL NEED SOMEONE TO DIEVE YOU HOME, NO MODE OF PUBLIC TRANSPORTATION WILL BE ALLOWD, INCLUDING TAXI S, BUSES OR WALKING ALONE. Pleas have your driver with you at Check-In to verify your ride. Please bring a list of all the medications you are now taking, including over-the-counter products and herbal supplements.

2800 E. Rock Haven Road, Harrisonville, Missouri 64701 Bring this completed form with you to your appointment. Name: M F DOB: Height: Weight: Referring Doctor: Previous Test Last GI Test (Colon, EGD, ERCP, Flex Sig, Barium Enema) Not Applicable Name of Test Date (Approximate) Where Hospitalization/Surgery (exclude normal pregnancies) Year Hospitalization/Surgery for: Year Hospitalization/Surgery for: If you have had past problems with anesthetic, including being told you require more medication than normal, please call (816)887-0457. Habits: Tobacco (What & how long) Packs per day Alcohol: Beer Liquor Wine Daily or Occasional Recreational Drug Use [ ] Yes [ ] No Pregnant [ ] Yes [ ] No Last menstrual period: Family History Please check the box that applies to each family member. Mother Father Siblings Gallstones Ulcers Polyps Pancreatitis Colon Cancer other Cancer - Specify Liver Disease (cirrhosis/hepatitis) Bleeding

2800 E. Rock Haven Road, Harrisonville, Missouri 64701 Bring this completed form with you to your appointment. Patient Name: DOB: Please all that apply. Respiratory Musculoskeletal [ ] Asthma [ ] Arthritis [ ] Dyspnea [ ] Joint Replacement within last year [ ] Sleep Apnea [ ] Muscle Weakness [ ] COPD [ ] Frequent Falls [ ] Cough lasting greater than 3 weeks [ ] Stiffness Cardiovascular Mental Health [ ] Hypertension [ ] Seizure Disorder [ ] Previous Endocarditis [ ] Depression [ ] Prostatic Heart Valve [ ] Bipolar [ ] Stroke/TIA [ ] Head Trauma [ ] Pacemaker/ICD [ ] Rheumatic Heart Disease [ ] Coronary Artery Disease [ ] Heart Attack [ ] Atrial Fibrillation Gastrointestinal [ ] Hepatitis [ ] Diverticulitis/Diverticulosis [ ] Hiatal Hernia [ ] Acid Reflux [ ] Ulcers [ ] Polyp [ ] Difficulty Swallowing [ ] Nausea [ ] Vomiting [ ] Diarrhea [ ] Unintentional Weight Loss [ ] Cirrhosis Endocrine/Renal [ ] Diabetes [ ] Anemia [ ] Thyroid (Hyper/Hypo) [ ] Kidney Failure Do you have an Advanced Directive? [ ] Yes [ ] No If no, do you need information? [ ] Yes [ ] No Do you have a Medical Durable Power of Attorney? [ ] Yes [ ] No If yes, please write the name and phone number.

Please bring this completed form with you to your appointment. Date: Patient Name: Date of Birth: In Order to give the best care possible, a complete list of medications is required. List all medications you take, including dosage, how often or what time(s) of the day you take them. Please include any over the counter herbs, remedies, vitamins, etc. that you may take as well. Medications; Prescriptions, & Over the counter Dose Frequency Continue Start Stop New Medications: Allergies Patient Signature Date/Time Physicians Signature Date/Time DISCHARGE INSTRUCTIONS: Manage Your Medications Keeping an accurate and current medication list is important to your health. Give a list to your Primary Care Provider and take a copy to every to every Physician visit. Update the list whenever there are changes in dose, new medications added or whenever medications are discontinued. Include any change you make in any of your over the counter medications. Carry your current medication list with you at all times.

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