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Fellow of the American College of Gastroenterology Faculty Lecturer, Mount Sinai School of Medicine You are scheduled to have an endoscopy on ___________________ at ___________ AM/PM
PLEASE MAKE SURE TO REVIEW THESE INSTRUCTIONS A WEEK BEFORE YOUR PROCEDURE!
THE WEEK BEFORE YOUR ENDOSCOPY

Make sure to arrange for an escort for the day of the procedure. Discuss with Dr Gutman and your cardiologist any blood thinners you are on including Plavix, Ticlid, Effient, Coumadin, Warfarin and Lovenox. You may stay on aspirin therapy up to 325mg daily. Discuss the use of arthritis and pain medications with Dr. Gutman. Avoid arthritis medications for 2 days before the test. These include naproxen (Naprosyn, Aleve), ibuprofen (Motrin, Nuprin) and many others. Mobic, Celebrex, and acetaminophen (Tylenol) do not need to be Avoid over the counter blood thinners such as Vitamin E and gingko biloba
If you have diabetes, do not take your insulin or diabetic pil s on the morning of the test. Please

advise your doctor so that he can arrange to have your blood sugar tested by finger stick on
the morning of the test and for you to receive the appropriate treatment as needed.
ON THE NIGHT BEFORE YOUR PROCEDURE, DO NOT EAT FOR 6 HOURS BEFORE THE
TEST. DO NOT DRINK FOR 4 HOURS BEFORE THE PROCEDURE.

ON THE DAY OF THE PROCEDURE
DO NOT EAT OR DRINK except medications until after the endoscopy.
Please take heart medications or blood pressure medications, other than water pills, 4 hours or more before
the appointment. Most other medications can be delayed until after the procedure.
You MUST have an escort to pick you up after the procedure. If you do not have an escort, the
procedure will be cancelled or rescheduled! If you have concerns about this requirement, please
discuss it with Dr Gutman.

QUESTIONS?
Call the office if you have any questions
DAVID GUTMAN,MD
516 739-4604
Fellow of the American College of Gastroenterology Faculty Lecturer, Mount Sinai School of Medicine Pre-Surgical Patient Questionnaire
PLEASE FILL OUT AND BRING WITH YOU ON TESTING DAY
1. What is the procedure you are having today? 2. Any major illnesses other than childhood diseases? 3. Have you ever had an operation? If so, please list them and the dates of surgery, if known 4. Please write in any medications, injections or pills that you take (this includes prescription drugs, over-the-counter drugs and vitamins) You may attach a printed list if you prefer
5. Do you have any allergies to specific medications? If so, please list them ‚ No Blood Relative has had Reaction to Anesthesia 6. Weight_____________________ Height______________________ 7. FEMALES: If you are under 55 and have had a period within the past year, you will be
8. Date of last menstrual period: _______ How many pregnancies have you had? ____ How many children have you had? _____ How many miscarriages or abortions? _____ 9. Is it possible you may be pregnant? _____________ Fellow of the American College of Gastroenterology Faculty Lecturer, Mount Sinai School of Medicine Pre-Surgical Patient Questionnaire
1. Any problems with your blood pressure, heart or circulation? (include history of chest pain associated with the use of nitroglycerin) 2. Any lung disease (eg. Bronchial asthma, emphysema), recent cough, cold or sore throat? 3. Any seizures, strokes, convulsions, blackouts, fainting spells, headaches? 5. Any disease of liver, jaundice, hepatitis, transfusion reaction? 6. Any bleeding disorder or bleeding tendency? 8. Diabetes or thyroid disease? (please circle which applies) 9. Do you have loose, false, chipped, capped, or bad teeth, bridges or dentures? 11. Have you taken cortisone by mouth in the past 12 months? 12. Have you taken nerve pills or tranquilizers in the past 2 weeks? 13. Do you have more than 2 alcoholic drinks per day?

Source: http://refluxny.com/wp-content/uploads/Upper-Endoscopy-2012a-Packet.pdf

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