Today's Date(XX-XX-XXXX):*

First Name:*

Last Name:*

Age:*

Gender:*
—Please choose an option—MaleFemale

Date of Birth (xx-xx-xxxx):*

Address (Address/City/State/Zip):

Contact Name:*

Contact Relationship:*
—Please choose an option—ChildGuardianParentSelfSpouseOther

Daytime Phone Number (XXX-XXX-XXX):*

Your Email*:

*By providing my email, I am consenting to have a Direct Access Colonoscopy confirmation email sent to the above listed email address.

What is the best time to contact you?*
—Please choose an option—AMPMAnytime

Insurance Carrier:*

Subscriber ID:*

Primary Care Physician:

Referring Physician:

Preferred Pharmacy:*
Pharmacy Name:*
Pharmacy Address:*

Preferred Physician:*
First AvailableScott A. Clark, MDSheraj Jacob, MDJohn L Kalarickal, MDNamita Pareek, MDVinni M. Reddy, MDNeeraj Sharma, MDAnkur Sheth, MDAndrew Lake, MD

Height (feet):*

Weight (lbs):*

Reason for Colonoscopy (Select all that apply):*
Screening (age over 50)Previous Colorectal CancerPositive Stool Test for BloodFamily History of Colorectal CancerPolyps removed previouslyOther, if so please specify

Have you had a colonoscopy previously?* YesNo
If yes, please provide the following details:Not Applicable
Procedure Year:
Performing Physician:
Facility:
City,State:
Procedure Findings:

Did you have any problems with the bowel prep? YesNo
If yes, please specify the problems you experienced with the bowel prep:Not Applicable

Have you experienced any of the following gastrointestinal symptoms in the past year:*
Black Stools: YesNo
Constipation: YesNo
Diarrhea: lasting more than 1 week: YesNo
Frequent abdominal pain: YesNo
Frequent nausea or vomiting:YesNo

Have you experienced any of the following medical issues in the past year:*
Abnormal heart rhythm: YesNo
Anemia (low blood):YesNo
Aneurysm:YesNo
Asthma:YesNo
Blood clot in legs:YesNo
Chest pain/ chest pressure:YesNo
Congestive heart failure:YesNo
COPD (Chronic obstructive pulmonary disease):YesNo
Diabetes:YesNo
Dialysis:YesNo
Emphysema:YesNo
Heart attack:YesNo
Heart valve problems:YesNo
High blood pressure:YesNo
High Cholesterol:YesNo
High thyroid:YesNo
Home oxygen: YesNo
Kidney failure:YesNo
Low thyroid:YesNo
Pacemaker or defibrillator:YesNo
Sleep apnea:YesNo
Stroke:YesNo
TIA (transient ischemic attack:YesNo

Have you recently experienced or are you currently experiencing any of the following symptoms:
Night Sweats? YesNo
Loss of Appetite? YesNo
Unexplained weight loss? YesNo
Anorexia? YesNo
Persistent cough for 3 or more weeks? YesNo
Bloody Sputum? YesNo
Fever? YesNo

How many stools do you have on a daily basis?

Have you ever been diagnosed with cancer?* YesNo
If yes, please provide primary organ affected and date of first diagnosis:Not Applicable

Have you experienced any other medical problems not mentioned above?* YesNo
If yes, please provide a description of symptoms or diagnosis you received: Not Applicable

Has either a parent, sibling, child, or grandparent been diagnosed with cancer of colon or rectum?*YesNo
If yes, what relationship and at what age was that person diagnosed with cancer? Not Applicable

Have any relatives had colon polyps?* YesNo
If yes, please list your relationship: Not Applicable

Have any relatives had any of the following? If yes, please specify the relationship:*
Breast Cancer: Not ApplicableParentGrandparentChildAunt/UncleCousin
Cirrhosis of liver: Not ApplicableParentGrandparentChildAunt/UncleCousin
Crohn's Disease: Not ApplicableParentGrandparentChildAunt/UncleCousin
Kidney Cancer: Not ApplicableParentGrandparentChildAunt/UncleCousin
Ovarian Cancer: Not ApplicableParentGrandparentChildAunt/UncleCousin
Pancreatic Cancer: Not ApplicableParentGrandparentChildAunt/UncleCousin
Sprue (Celiac Disease): Not ApplicableParentGrandparentChildAunt/UncleCousin
Stomach Cancer: Not ApplicableParentGrandparentChildAunt/UncleCousin
Ulcerative Colitis: Not ApplicableParentGrandparentChildAunt/UncleCousin
Uterus Cancer: Not ApplicableParentGrandparentChildAunt/UncleCousin

Have you had any problems with sedatives or anesthesia in the past?* YesNo
If yes, please specify the problems you experienced with sedatives or anesthesia: Not Applicable

Have you had any surgeries in the past?* YesNo
If yes, please list all surgeries you've had with approximate dates:Not Applicable

Have you had to stay in the hospital overnight for anything besides surgeries?* YesNo
If yes, list the medical conditions that were treated and give the approximate dates: Not Applicable

Are you currently prescribed to any medications?* YesNo
If yes, list all prescription medications you are taking, and their doses: Not Applicable

Are you currently taking any non-prescription medications?* YesNo
If yes, list all non-prescription medication you have taken in the last few weeks, or that you take frequently. Include pain-killers, vitamins, laxatives, and how often you take each: Not Applicable

Are you currently prescribed to any blood thinning medications(Examples: Coumadin (Warfarin), Plavix, Aggrenox, Pletal)?*YesNo
If yes, list the type of blood thinning medication that you are prescribed, dosage and the conditions that you are taking this medication for:Not Applicable

Do you have any allergies to medications?*YesNo
If yes, list the medication and reaction:Not Applicable

Do you smoke cigarettes?*YesNo
How many per day? Not Applicable

How many years? Not Applicable

How many alcoholic beverages do you usually drink in a week?*
None1-34-78-1415-21More than 21

If you have anything to add that wasn't included in this form, please describe it below:Not Applicable

Agreement/E-Signature Disclaimer:
By selecting the "I agree" checkbox, and filling in the below signature box I agree to the following: I acknowledge the risk of sending information by email and will not hold Gastroenterology Associates of Gainesville, P.C. responsible for any damages you may incur as a result of the transfer or use of this information. I understand the use or transmittal of this form does not create a physician-patient relationship. I am giving representatives from Gastroenterology Associates of Gainesville, P.C. permission to contact me between 8:00 am and 5:00 pm EST to schedule a Direct Access Colonoscopy procedure. In addition, I declare that the information provided on this form, is to the best of my knowledge, true and correct.

Patient Acceptance (First Name, Last Name):
agrees to the terms and conditions listed above.

I AGREE *

Important: After submission, please do not leave this form until you see the confirmation message.