Instructions for Upper Endoscopy (EGD) and possible Biopsy
ThinkPark Tower Gastroenterology Clinic
3rd floor ThinkPark Tower Medical Center room#1
2-1-1 Osaki Shinagawaku, Tokyo 141-6003 Japan
phone 03-5745-3088 Fax 03-5745-3089
HP: http://www.thinkparkclinic.com
info@thinkparkclinic.com
cell 090-9954-6303 Email: lisana773@gmail.com
Patient Name: ___________________________________
Appointment date and time: _____/_____/______ at_____:____ [ ] am [ ] pm
Welcome to ThinkPark International Clinic. You have been scheduled for a procedure called
an esophagogastroduodenoscopy (EGD). This procedure usually takes approximately 20minutes. Be sure to bring the questionnaire and documents provided with you on the day of yourprocedure.

< What is an Upper Endoscopy? >An Upper Endoscopy is a test that uses a scope to look inside your esophagus,
stomach and first part of the small intestines called the duodenum. It is done to findout the reason for• difficulty swallowing• nausea or vomiting• pain in the stomach or abdomen• bleeding• ulcers, gastritis or cancers• chest pain
• infection with helicobacter pylori (specific test is available with procedure)
During the test you will swallow a long thin flexible tube called an endoscope. A small
camera is attached to the scope so that your doctor can take pictures of theesophagus, stomach, and duodenum.
The endoscope allows the doctor to• See abnormalities like inflammation or bleeding• Take samples of abnormal areas called a biopsy• Stop bleeding• Remove polyps
An upper endoscopy is a very safe procedure. However, there are some risks orproblems that might occur with the test and medication used.
Complications that may occur include:１• Sore throat or infections, bleeding, or damage to teeth• Abdominal cramps• Adverse reaction to the medications or agents, including inflammation of the veinat the IV site
•Temporary slowing of the heart rate or a decrease in breathing or a drop in bloodpressure• Serious medical problems that can result include: Perforation, a tear in the wall of
the intestines. If this happens it is treated with hospitalization and antibiotics orsurgery.
< A week before endoscopy>•If you take Plavix, Coumadin (Warfarin), Aspirin or any other blood thinning
medications, please discuss with the doctor who proscribed these medications if you
could temporally stop the medications a week before the procedure to prepare for abiopsy.
< The day before endoscopy>•Don’t eat food after 8 pm, and drink water or clear liquids (Such as sports drinks,Sprite, or tea) only (no milk, colored liquids or juices).
•Take cardiac medication such as nitroglycerin, anti-hypertensive regularly. Do not takediabetic medications while fasting. Ask individual medical questions you might have.
< During the endoscopy>• Take off the accessories you are wearing, such as rings, neckless, glasses ordentures, if possible, and safely keep them by yourself.
•An intravenous (IV) line will be put in your arm. You will be given medications though
the IV that will help you relax and may make you drowsy.
The doctor will spray the back of your throat with numbing medicine.
You will be asked to lie on your left side.
The doctor will pass the endoscope, a very thin flexible tube through your mouth into
your esophagus, stomach and duodenum.
< After the procedure>• Your throat may be numb from the local anesthesia which is applied by spray andmight cause you to choke on foods or drinks. Wait more than 30 minutes to drink awater or to eat an easily digestible diet or very light soups etc., or follow theinstruction provided by the doctor.
• You will not be able to drive afterwards If you receive procedural sedation that will
make you sleepy and drowsy. If you have someone available to drive you home oraccompany you home in a taxi or on public transportation after your procedure, it will
be necessary.

２

ThinkPark Tower Gastroenterology Clinic

Patient Questionnaire and Consent Form
Name________________________________ ☐ Male ☐ Female
Date of Birth_______________________________ years old

Address__________________________________________________________________________
Phone number_________________________• Current Medications, Prescription / Over the Counter
Medication Name
Dose

Last Time Taken___________________________ ___________________ ________________________________________________ ___________________ ________________________________________________ ___________________ ________________________________________________ ___________________ _____________________•Are you taking blood thinning medications such as Plavix, Coumadin (Warfarin), Aspirin or any others?
Medication NameDose

Last Time Taken___________________________ ___________________ _____________________•Personal Medical History. If checked, please explain☐ High Blood Pressure ()☐ Diabetes()☐ Heart Disease()☐ Lung Disease()☐ Liver Disease()☐ Kidney Disease ())☐ Others)☐ Allergies ((☐ Anesthetic/side effect or allergy ()☐ Surgical Histories ()☐ Pregnant ()Prostatic Hypertrophy ()I understand the professional will do the best and appropriate managements under this procedure if any
unexpected conditions occur. I was informed the benefits and risks of the performance and agree to havethis procedure. I will follow the instruction direct by Doctors and Medical assistances.

Signature_______________________________ date_________________
３