Open Access Colonoscopy Questionnaire

Regular colonoscopy screenings, beginning at age 45, is the best way to find colon polyps and detect colorectal cancer early. In the U.S., colorectal cancer is the third most common cancer. A colonoscopy is a safe procedure that allows your doctor to inspect the lining of your lower gastrointestinal (Gl) tract, or rectum and colon. As with any procedure complications can occur. Our open access program makes it easy to get scheduled for your procedure and forgo an office visit first. To get started, just complete this form in its entirety. This will allow our office to determine if open access is the best choice for you. If not, our office will set up an appointment for you to consult with one of our physicians. If you are not sure how to answer a question, you may leave the question blank. A member of our medical staff will go over all your answers with you during the follow up call.

Patient Demographic Information

Full Name

Date of Birth

Last 4 of SSN

Mailing Address

Apt #

City

Zip Code

Home Phone

Cell Phone

Email Address

Age

Sex

Race

Ethnicity

Preferred Language

Marital Status

Emergency Contact Name

Relation to You

Phone

Can our office release personal health information to your emergency contact listed above?

Yes No

Name of Primary Care Provider

I do not have a primary care provider

Name of Referring Physician

I do not have a referring physician

Other physicians you would like your report(s) sent to

Insurance Information

I do not have health insurance and will be paying out of pocket for my procedure.

Name of Insurance Carrier

Member ID #

Claims Address

Group #

Subscriber Name

Relation

DOB

Kindly upload a photo of your insurance and ID card.

Insurance

Add file

Please upload a file

Add file

Please upload a file

Patient Health Information Past or Present

1. Height

Weight

2. Are you pregnant or trying to become pregnant?

Yes No

3. Immunizations:

Flu Vaccine (MM/YY)

Hep A

Hep B

Pneumonia (YYYY)

4. Tobacco

Never smoked

Current, everyday smoker

Occasional smoker

Former smoker

Number of cigarettes per day

Year Quit Smoking

5. Alcohol

None

Occasional

Social

Moderate

Heavy

Recovering alcoholic

6. Drug Use

None

History of IV drug use

Current recreational drug use

Former recreational drug use

Current use of marijuana

Patient Medication Information

Pharmacy Name

City

List of medications, prescribed, over the counter & supplements. Include name, strength and times taken per day:

Allergies? (List allergy and reaction)

No known allergies

Do you currently take any of the following medications:

I am not taking any blood thinners or NSAIDS.

Aspirin, Aleve, Advil, Ibuprofen, Voltaren

Plavix (Clopidogrel)

Coumadin (Warfarin)

Ticlid (Ticlopidine)

Eliquis (Apixaban)

Xarelto (Rivaroxaban)

Lovenox

Heparin

Colonoscopy & Abdominal Health History

1. Do you have a family history of colon cancer or polyps?

Yes No

If YES, Select the relatives with a history of colon cancer or polyps:

Mother

Father

Sister

Brother

Child

No known family history

Specify age

2. Have you had a colonoscopy before?

Yes No

IF YES, how many?

Date of your last colonoscopy?

Where was your colonoscopy performed?

Were polyps removed?

Yes No

IF YES, how many?

3. Did you have any complications from your procedure?

Yes No

If YES, Select all that apply

Abdominal pain

Nausea/Vomiting

Bowel Perforation

Difficult/Tortuous Colon

Abdominal Gas / Bloating

Fever

Rectal bleeding after procedure

Sedation Issues

Other

If other, please specify.

4. Have you ever been diagnosed with colorectal cancer?

Yes No

If YES, when? (date)

Where was your colonoscopy performed?

Name of the oncologist that treated you?

5. Have you been seen by a gastroenterologist in the past?

Yes No

If YES, What is the name of the physician?

6. Have you ever been diagnosed or treated for any cancer of an abdominal organ (prostate, ovary, uterus, liver, gallbladder, pancreas, small bowel, stomach or abdominal lymphoma)

Yes No

If YES, what organ

7. Have you had any surgery to your abdomen?

Yes No

If YES, Select all that apply:

Appendectomy

C-Section

Gastric Bypass

Hernia Repair

Bowel Resection

Gallbladder Removal

Hysterectomy (Uterus Removal)

Other Abdominal Surgeries

If other, please specify.

8. Check any gastrointestinal conditions you’ve had in the past 3 months.

Select all that apply:

Ulcerative Colitis

Crohn’s Disease

Diarrhea lasting more than a week

Rectal bleeding

Black tarry stool

Hemorrhoids

Constipation

Frequent abdominal pain

Patient past or present medical conditions

KIDNEY DISEASE

No Issues

Chronic kidney disease

Dialysis

PULMONARY

No Issues

Asthma

Sarcoidosis

COPD

Sleep apnea

Home oxygen

Shortness of breath

Pulmonary Hypertension

ENDOCRINE

No Issues

Diabetes

Thyroid Disease

NEUROLOGICAL

No Issues

Multiple Sclerosis

Parkinson’s

Stroke

Other

If other, please specify.

MUSCULOSKELETAL

No Issues

Paralysis/Paresis of extremities

Neuromuscular Disease

If you have any other medical condition or concern that was not included in this form, please describe below:

Patient Consent for Open Access Colonoscopy

I consent for Digestive Health Consultants to obtain a history of my medications from my pharmacy.

Yes No

I consent for Digestive Health Consultants to obtain my previous colonoscopy report and pathology.

Yes No

I have reviewed the open access questionnaire and I declare that the information I have given on this form is to the best of my knowledge, true and complete. I understand that incomplete or false information may result in unexpected complications related to the colonoscopic procedure itself or to the sedation. These complications, which may happen even in excellent health, may include abdominal pain and bloating, bleeding, bowel perforation, and reaction to medications. I also understand and accept the fact that my colonoscopy may not be complete due to inadequate preparation of the colon, my reaction to medications used for conscious sedation or propofol or excessive risk complications, as decided by the performing physician, before or during my procedure. In such case, I may choose to have another colonoscopy at another time. Finally I may choose to not to have any follow-up screening procedure and I understand the possible risks of such a decision.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Patient Name

Date

Your information will be encrypted.