Direct Access Questionnaire

Date

Physician

Referring Physician

Patient's Name

Date of Birth

New Patient

Follow Up

Home Phone

Cell Phone

Email address

Pharmacy

Pharmacy Phone

Pharmacy Location

Reason for Colonoscopy

Screening

HX Colon Ca

HX Colon Polyps

FHx Colon Ca

FHx Colon Polyps

Have you had a colonoscopy in the past?

Yes No

If yes, When?

Where?

Results

Normal

Polyps

Cancer

Other

Other:

Do you have any Gastrointestinal Symptoms

Abdominal Pain

Bleeding

Anemia

Other

Weight

Height

BMI (> 50 Make office Visit)

MEDICATIONS

Add Additional Medications

ALLERGIES:

If yes to any of the above questions, schedule patient for an office visit

If Other, Please specify

If yes, what type?

If yes, Details?

If yes, What type?

If yes, How Often?

How Much

How often do you have a bowel movement?

Daily

2-3 x's day

Every other day

Other

If other, please specify

Scheduler

Procedure Date

Time

Endo Center

OTEC

RBEC

CPEC

PVEC

NRHEC

Other

If Other, Please specify

Prep

Mailed

Emailed

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Patient's Name / Signature

Date

PHYSICAL EXAM

HEENT

NECK

LUNGS

ABD

EXT

NEURO

Reviewed by DHAT Physician

Date

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Direct Access Questionnaire

MEDICATIONS

If yes to any of the above questions, schedule patient for an office visit

Digestive Health Associates of Texas

Sindhu Abraham, M.D.