Direct Access Colonoscopy Form

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Thank you for choosing our practice for your gastrointestinal health. Please complete the form below to submit a request for a Direct Access Colonoscopy with one of our Board-Certified Gastroenterologists. This service is not intended for urgent or emergency situations, as online request are handled Monday through Friday, 8:00 am to 5:00 pm.
If you are having an emergency, call 911 immediately or go to the nearest emergency room.
(*) equals a required field

Direct Access Colonoscopy Pre-Qualification Questionnairre

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

    First Name:*

    Last Name:*

    Age:*

    Gender:*

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

    Address (Address/City/State/Zip):

    Contact Name:*

    Contact Relationship:*

    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?*

    Insurance Carrier:*

    Subscriber ID:*

    Primary Care Physician:

    Referring Physician:

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

    Preferred Physician:*

    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.

    If you have additional questions, please contact us at 770-536-8109 our associates will be happy to assist you.

         

    Gastroenterology Associates Pathology Department
    Our compliance with the National Patient Safety Goals
       was validated by the Joint Commission in January 2019