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UPDATED COVID-19 Resources
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Open Access Screening Tools
Section 1
Today's Date
*
Month
Month
Jan
Day
Day
30
Year
Year
2023
Name
*
Date of Birth
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Section 2
Contact Number
*
Weight
*
lbs
BMI
*
Referring Provider
*
Section 3
Have you had a colonoscopy before?
*
Yes
No
How long ago?
Where?
Findings or recommendations?
Any family history of Colon Cancer or Polyps?
*
Yes
No
Who?
Do you have Crohn's Disease or Ulcerative Colitis?
*
Yes
No
Describe
Have you had any difficulty with anesthesia?
*
Yes
No
What type of difficulty?
Do you have bleeding?
*
Yes
No
Describe
Do you have changes in bowel habits?
*
Yes
No
Describe
Do you changes in texture of stool?
*
Yes
No
Describe
Do you have a history of anemia?
*
Yes
No
Describe
Do you have diarrhea?
*
Yes
No
Describe
Do you have Constipation?
*
Yes
No
Describe
Do you have a history of heart disease, heart failure, valve problems or chest pain?
*
Yes
No
Describe
Do you have a pacemaker or implantable defibrillator?
*
Yes
No
Describe
Do you have Emphysema, COPD, Asthma, Sleep Apnea, or Shortness of Breath?
*
Yes
No
Describe
Do you use oxygen?
*
Yes
No
Describe
Do you use a CPAP machine?
*
Yes
No
Describe
Do you have kidney disease?
*
Yes
No
Describe
Do you have diabetes?
*
Yes
No
Do you use insulin?
Do you take blood thinners such as Coumadin, Plavix, or other?
*
Yes
No
Describe
Could you be pregnant?
*
Yes
No
Do you have allergies?
*
Yes
No
Describe
Please list any medications
Submit