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COVID-19 Self-Evaluation

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Open Access Screening Tools

Section 1

Today's Date *

Month

Day

Year

Name *

Date of Birth *

Month

Day

Year

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

Insurances Accepted

New Patient Paperwork

About Lovelace Health System

Lovelace Health System is comprised of Lovelace Medical Center, Heart Hospital of New Mexico at Lovelace Medical Center, New Mexico Heart Institute, Lovelace UNM Rehabilitation Hospital, Lovelace Women's Hospital, Lovelace Westside Hospital, Lovelace Regional Hospital and Lovelace Medical Group/Southwest Medical Associates.

Have a question? Call us @ 505.727.8000

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Hospitals in Albuquerque and Roswell, New Mexico
4101 Indian School Rd NE, Albuquerque, NM 87110
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