Atul T. Shah, M.D., P.A.
Samir K. Nath, M.D., P.A.
Phone # (281)422-7970 Fax # (281)422-7960
COLONOSCOPY WITH POSSIBLE BIOPSY AND POLYPECTOMY
NAME:
SEX:
PATIENT HOME #
DIAGNOSIS:
DOB:
DATE:
Abdominal pain
Family history of colon cancer
Personal h/o colon polyp
Rectal bleeding
Rule out colitis
H/o diverticulosis
Rule out colon polyp
Change in BM habits
Guaiac positive stool
Procedure Risks: Perforation, Bleeding, Infection, and Medication Reaction
COLYTE PREPARATION INSTRUCTIONS FOR THE PATIENT
A. Registration at:
Your Colonoscopy is scheduled at on _______, ____/____/20__at___AM
[] Pregnancy Test
B. Preparation for the Colonoscopy
One week before the procedure:
 Do not take any form of Aspirin/ STOP VITAMINS
Three days before the procedure:
Do not take NSAIDs (i.e., Advil, Ibuprofen) Tylenol is okay.
START BY TAKING 2 TABLETS OF DULCOLAX AT BEDTIME ON _________,
____________/____20__. THE NEXT MORNING, WHICH IS THE DAY OF PREPARATION FOLLOW
THE DIRECTIONS AS FOLLOWS:
 No Solid Foods upon arising.
 Take clear liquid diet (Broth, Water, Juices, Jell-o, Coffee, Tea or Soda) Start early in the morning.
 No milk or milk products. No liquids in red or purple color.
WHEN YOU START THE COLYTE PREPRATION TO CLEAN THE BOWEL,
 You need one gallon of distilled water and refrigerate. Get Colyte prescription filled.
 Drink CoLYte starting at 10:00am until 1:00pm or, as directed.
 You may flavor per glass with Crystal Light or Lemon juice.
 While drinking Colyte, if you experience nausea, wait for one hour and start drinking again.
 If, after one hour interval, you are still unable to drink Colyte call (281) 422-7970
 AFTER FINISHING THE COLYTE YOU WILL NEED TO FOLLOW WITH THE 2
ADDITIONAL DULCOLAX TABLETS.
 Resume clear liquid diet. It is important to drink liquids, so you will not dehydrate.
DO NOT DRINK OR EAT ANYTHING AFTER MIDNIGHT OR MORNING OF PROCEDURE
C. Day of the Procedure:
 Be at ______________________ Unit at ______ am
 Please be sure to bring your procedure order with you.(or you will be rescheduled)
 Bring your medication with you. DO NOT take them.
 You will need to bring someone with you to drive you back home.
 Special Instructions if any:________________________________________________
Insurance Company: ___________________________
Schedule Completed by: ______________________
MAC
NO
YES
PEDISCOPE
NO
YES
_____________________________________________
Atul. T. Shah, M.D./ Samir K. Nath, M.D.