Direct Access Colonoscopy Screening Questionnaire

Today’s Date

Last Name

First Name

Date of Birth

Sex

Male Female

Telephone #

The reasons for the colonoscopy are (check all that apply):

Screening (age over 45)

Yes

No

Previous personal history of colon cancer

Yes

No

Family history of colon cancer

Yes

No

Polyps removed at a previous colonoscopy

Yes

No

Hidden blood found in stool

Yes

No

Blood test abnormality

Yes

No

Does patient have any symptoms?

Rectal bleeding

Yes

No

Change in bowel habits

Yes

No

Constipation

Yes

No

Diarrhea

Yes

No

Abdominal pain

Yes

No

Nausea

Yes

No

Vomiting

Yes

No

Other

Does patient take any blood thinners (such as Coumadin, Eliquis, Plavix, Xarelto)?

Yes

No

Direct Access Colonoscopy Screening Questionnaire

Please fax this form and a copy of patient’s ID and insurance card to (630) 889-8977.