Upper Endoscopy Questionnaire
What an upper endoscopy questionnaire asks, with sample questions on past EGDs, medicines, anesthesia, and the ride home.
An upper endoscopy questionnaire records the reason for the EGD, past endoscopies, medicines, health conditions, and anesthesia history before the procedure. It's also called an EGD questionnaire or an upper endoscopy health history.
Upper endoscopy questionnaire, handled by the AI Doctor avatar
AI Doctor, a real-time AI healthcare assistant avatar, asks the questions on an upper endoscopy questionnaire in the patient's own language, strictly following the practice's instructions.
- Intake before the visit. Patients answer online before they arrive, or at a kiosk when they check in.
- Answers ready for the clinician. Clinicians see what the patient said before the visit starts.
- Less workload at the front desk. Staff spend less time handing out forms and entering answers by hand.
- Key details at a glance. The care team sees what matters up front and decides who needs attention first.
The form becomes a natural conversation: patients answer by talking, in their own words. AI Doctor is an information and patient-assistance interface. It collects answers for the care team to review. It doesn't diagnose, triage, or give treatment advice.
Sample upper endoscopy questionnaire questions
Typical questions, written out so you can see the level of detail. Every practice words its own form differently.
- Why are you having an upper endoscopy?Procedure reason
- Which symptoms led to the procedure?Procedure reason
- When was your last upper endoscopy?Past endoscopy
- Have you been diagnosed with Barrett's esophagus?Past endoscopy
- Do you take blood thinners or antiplatelet medicines?Medicines
- Do you take any medicines for diabetes?Medicines
- Do you have heart or kidney disease?Health history
- Have you had a recent cold or asthma flare?Health history
- Have you had problems with anesthesia before?Anesthesia history
- If so, what happened with the anesthesia?Anesthesia history
- What is your driver's name and relationship?Driver details
- What is the best number to reach your driver?Driver details
These are examples to read, not a form to fill in.
Upper endoscopy questionnaire: FAQ
What does an upper endoscopy questionnaire ask?
The sample questions on this page are based on the HealthPartners health history form and a gastroenterology practice's endoscopy health history form. This page groups them into six areas: procedure reason, past endoscopy, medicines, health history, anesthesia history, and driver details.
Who fills in an upper endoscopy questionnaire, and when?
The patient, ahead of the procedure. Both source forms ask the patient to complete them and bring them along on the day of the endoscopy.
Is it the same as an EGD questionnaire?
Yes. The HealthPartners form lists the procedure as Upper Endoscopy (EGD), so the two names refer to the same procedure.
Does it ask about acid reflux?
Yes. The HealthPartners form asks patients having an upper endoscopy about a past diagnosis of GERD or acid reflux and of Barrett's esophagus, with the year.
Does this page give fasting or prep instructions?
No. Fasting, medicine, and arrival instructions come from the practice that performs the endoscopy; this page shows only the questions asked beforehand.
What happens after the upper endoscopy questionnaire is completed?
The practice's team reads the answers before the procedure and follows its own protocol. AI Doctor only collects them and does not judge whether sedation is safe.
Does AI Doctor give medical advice?
No. It collects information for the care team. It doesn't diagnose, triage, or recommend treatment.
Can patient answers stay on our own servers?
Yes. RAVATAR offers on-prem deployment: the platform can run inside your own perimeter, so patient answers stay there. RAVATAR complies with GDPR and the EU AI Act.
Set up your AI Doctor in Genesis AI Avatar Studio
Genesis AI Avatar Studio is where you set up, test, and publish AI avatars for your website, mobile app, or Holobox. No coding or technical skills needed.
- 01Choose the AI Doctor avatar.
- 02Add your practice's FAQs and visit information.
- 03Talk to it, then publish it.
