Gastrointestinal Associates, Inc.
Open Access Colonoscopy Questionnaire
Gastrointestinal Associates has developed a program which allows healthy individuals to schedule screening
colonoscopy without the need for an office visit before the procedure.
EVERY QUESTION MUST BE ANSWERED OR WE WILL NOT BE ABLE TO SCHEDULE AN OPEN ACCESS COLONOSCOPY. Be advised that a Nurse from our office will review, and depending upon the answers, you may need to have an Office Visit prior to the Colonoscopy.
Someone from our office will contact you.
Open Access Colonoscopy at our institution is approved for patients age 45 to 70 in good health.
How old are you now?
Those who desire colon cancer screening below age 45 or above age 70 are encouraged to schedule an office visit to determine if screening is medically appropriate.
What is your height?
What is your weight(lb)?
Do you have any gastrointestinal symptoms such as
Do you have or have been treated for any of the following?
ulcerative colitis or Crohn’s disease
heart attack, irregular heartbeat, coronary artery bypass or stent placement, congestive heart failure
bypass or stent placement, congestive heart failure
stroke, seizure,or fainting spells
renal failure or dialysis
sleep apnea or respiratory problems (COPD, emphysema, home oxygen or active asthma)
defibrillator, pacemaker, or artificial heart valve
organ transplant other than cornea
Do you experience chest pain or shortness of breath?
Do you take any blood thinners other than aspirin?
Have you had a colonoscopy in the past?
Do you have a family history of Colon Cancer or Polyps?
If Yes, which relative had cancer or polyps and how old were they?
Are you taking any medications for High Blood Pressure?
Do you: Smoke?
Use any illicit drugs?
Do you have any medication allergies? Please list.
List all medications that you take including herbals and over the counter medications:
Have you had difficulty with anesthesia other than nausea?
If yes, describe the difficulty
Have you had Colon Surgery(NOT A COLONOSCOPY)?
If yes, describe the surgery and the date you had it.
Have you had Joint Replacement Surgery in the last 3 months?
Have you ever had any of the following surgeries?
Are you able to walk without help?
Is there a Physician you prefer to be scheduled with? Name:
Do you prefer Male of Female?
Gastrointestinal Associates (OAC)
1095 Rydal Road, Suite 100
Rydal, PA. 19046
Gastrointestinal Associates (OAC)
708 Shady Retreat Road, Suite 9
Doylestown, PA 18901
Patient Statement for Open Access Colonoscopy:
I have reviewed the Open Access Colonoscopy Questionnaire and have answered all questions truthfully to the best of my knowledge.
Open Access Colonoscopy is designed to allow healthy, age appropriate patients to have a screening colonoscopy without an office visit. The Questionnaire that I have completed will be carefully reviewed and I may be called for points of clarification. For my safety, depending on the answers provided, I understand I may be scheduled directly for a Screening Colonoscopy or if I do not meet open access criteria, an office visit will be scheduled.
I understand that by choosing to pursue Open Access Colonoscopy I have not, nor during this process will I have, a GI consultation. I understand that I have the choice to make an appointment for an office visit to discuss colonoscopy and the risk, benefits and alternatives and have declined to do so. I also understand that I will require a separate office visit to address any GI complaints I might have.
If I am scheduled directly for a Screening Colonoscopy I will be sent information by mail regarding preparation for the procedure, the procedure itself, and post-procedure concerns. I will read the information provided and make sure that I understand and will be able to comply with the instructions given.
I understand that, while not likely, there are risks involved with colonoscopy as with any medical procedure. These risks are outlined in the information that I have received. I have reviewed this information to my complete satisfaction and I understand the risks and the benefits of colonoscopy.
Should I have any changes in my health status or insurance after being scheduled, or any questions about the information I receive by mail I will call the office at 267-620-1100.
I understand that I must have someone drive me to the procedure and wait in the unit to drive me home. Without a driver in attendance the procedure will be cancelled.
GASTROINTESTINAL ASSOCIATES, INC.
Welcome to our practice. Please complete all sections of this registration form. Thank you.
Date of Birth:
Emergency Contact Name:
Federal Government Requirement:
Hispanic or Latino
Non-Hispanic or Non-Latino
Pharmacy Name, Address, Phone#, Fax#:
Mail Order Pharmacy Name, Address, Phone#, Fax#:
Primary Care Physician:
Insurance Company Information
Patient’s Relationship to Insured Party (Circle One):
Primary Insurance Co.
Secondary Insurance Co.
I AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE THIS INFORMATION TO
THE SOCIAL SECURITY ADMINISTRATION, HEALTH CARE FINANCING ADMINISTRATION, MY INSURANCE
COMPANY OR ITS INTERMEDIARIES OR CARRIERS, OR TO THIS PHYSICIAN'S OFFICE OR TO MY ATTORNEY OR
OTHER DOCTOR’S OFFICE.
I AUTHORIZE DIRECT PAYMENT OF MEDICAL BENEFITS AND/OR SURGICAL BENEFITS, TO INCLUDE MAJOR MEDICAL BENEFITS TO WHICH I AM ENTITLED, INCLUDING MEDICARE, PRIVATE INSURANCE, AND ANY OTHER HEALTH PLAN TO
GASTROINTESTINAL ASSOCIATES, INC. I ALSO PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE 01’
THE ORIGINAL. ThIS ASSIGNMENT WILL REMAIN IN EFFECT UNTIL REVOKED BY ME IN WRITING. I UNDERSTAND
THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY SAID INSURANCE.
COLONOSCOPY INFORMATION SHEET
This information sheet is provided to help you understand colonoscopy. If you have questions
after reading this sheet, please do not hesitate to ask them. Upon your arrival at the facility for
your procedure you will be asked to sign a consent form.
WHAT IS COLONOSCOPY?
Colonoscopy is an examination of the large intestine using a flexible tube (colonoscope) with a
video camera at the end. The tube is inserted into the rectum and advanced through the colon.
At the time of the examination the doctor can take tissue samples (biopsies) or remove abnormal
growths such as polyps. Other procedures are sometimes performed such as applying clips or
electrocautery to prevent or control bleeding, or injecting fluid or dyes into the bowel wall.
Patients usually receive a sedative medication injected through an intravenous line (IV) and are
sleepy or asleep throughout the procedure. On average, the procedure takes between 20 minutes
and an hour.
WHY IS COLONOCOPY DONE?
Colonoscopy is done to detect colon cancer or pre-cancerous polyps in both average risk
individuals and in those with an increased risk of colon cancer, such as those with a family
history of colon cancer or a personal history of inflammatory bowel disease. It is also done as
part of the evaluation of symptoms such as rectal bleeding, diarrhea, change in bowel habits, and
WHAT IS THE SUCCESS RATE OF COLONOSCOPY?
An examination of the entire colon is possible in most patients. Occasionally a complete
examination is not possible because of narrowing of the colon, the presence of an unusually long
and twisty colon, or looping and sharp angulation (usually from scarring related to previous
surgery or diverticulitis). Even when the entire colon can be reached with the colonoscope, there
is a chance that a polyp or other abnormality will not be seen. This chance is higher when pre-
colonoscopy cleansing of the colon is not adequate, but still exists even when the colon is well
prepared. If the examination is incomplete, you may need additional testing such as barium
enema x-ray or CT colonography (“virtual colonoscopy”), or perhaps another colonoscopy.
WHAT ARE THE RISKS OF COLONOSCOPY AND ASSOCIATED PROCEDURES?
Colonoscopy is considered a relatively safe procedure, but serious complications occur in about
1 person out of 1000 (0.1%). These complications include infection, perforation (puncture or tear
of the bowel wall creating a hole), bleeding (frequently from a treatment site, such as the place
where a polyp was removed), cardiac problems such as heart attack or rhythm disturbances,
sedation related complications such as aspiration or decreased respiration, and even death which
is quite rare. While a complete listing of possible rare complications would be quite lengthy, this
list includes some of the most significant risks.
WHAT ARE THE ALTERNATIVES TO COLONOSCOPY?
There are several other methods which can be used to examine the bowel. These include a
limited examination which is confined to the rectum and lowest portion of the colon (flexible
sigmoidoscopy), barium enema x-ray, and CT colonography (“virtual colonoscopy”).
Examination of the stool for the presence of microscopic amounts of blood can be used as a
screening technique for colon cancer.
WHAT CAN I EXPECT AFTER THE PROCEDURE?
You may feel bloated or have cramping for 1-2 hours after the procedure is completed. You may
feel tired and need to take a nap once you are back home. It is common to go for a day or two
without a bowel movement. If biopsies are done or a polyp is removed, you may see a small
amount of bleeding from the rectum. You should plan to eat a light meal after the procedure, and
then return to a normal diet if you are feeling fine. You should be completely recovered and able
to return to your usual activities by the next day. You cannot drive for a minimum of 12 hours
after your sedated procedure.