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.

1. Open Access Colonoscopy at our institution is approved for patients age 45 to 70 in good health.

   Your current age is
   
   

   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.

2. What is your height?
   

   What is your weight?
   

   BMI:
   

3. Do you have any gastrointestinal symptoms such as

   • abdominal pain Yes    No
   • bleeding Yes    No
   • weight loss Yes    No
   • difficulty swallowing Yes    No
   • frequent diarrhea Yes    No
   • personal history of Colon Cancer Yes    No

4. Do you have or have been treated for any of the following?

   • ulcerative colitis or Crohn’s disease Yes    No
   • heart attack, irregular heartbeat, coronary artery bypass or stent placement, congestive heart failure Yes    No
   • bypass or stent placement, congestive heart failure Yes    No
   • stroke, seizure,or fainting spells Yes    No
   • renal failure or dialysis Yes    No
   • sleep apnea or respiratory problems (COPD, emphysema, home oxygen or active asthma) Yes    No
   • defibrillator, pacemaker, or artificial heart valve Yes    No
   • organ transplant other than cornea Yes    No
   • diabetes Yes    No
   • bleeding disorders Yes    No

5. Do you experience chest pain or shortness of breath?

   Yes    No

6. Do you take any blood thinners other than aspirin?

   Yes    No

A response to all questions is required in order to move forward with the submission

7. Have you had a colonoscopy in the past?   

   Yes    No

   
   If the answer is yes
   • Was this completed by a physician with Gastrointestinal Associates?    Yes    No
     
   • Date of Colonoscopy:
   • Facility where colonoscopy was completed:
   • Physician completing colonoscopy:
   • Phone number of physician completing colonoscopy:
8. Do you have a family history of Colon Cancer or Polyps?    Yes    No
   If Yes, which relative had cancer or polyps and how old were they?
   
9. Are you taking any medications for High Blood Pressure? Yes    No
10. Do you currently smoke? Yes    No
11. How often do you drink alcohol? Never    Daily    Weekly    Monthly
12. Do you use any illicit drugs? Yes    No
13. Do you have any medication allergies?    Yes    No
    If Yes, Please list.
    
14. a. Do you take any prescription medications?    Yes    No
    If yes, please list all prescription medications that you take:
    b. Do you take any herbals and over the counter medications?    Yes    No
    If yes, please list all other medications that you take:
    
15. Have you had difficulty with anesthesia other than nausea? Yes    No If yes, describe the difficulty
    
16. Have you had Colon Surgery (NOT A COLONOSCOPY)? Yes    No If yes, describe the surgery and the date you had it.
    
17. Have you had Joint Replacement Surgery in the last 3 months? Yes    No
18. Have you ever had any of the following surgeries?
    • obesity surgery Yes    No
    • appendectomy (appendix removal) Yes    No
    • cholecystectomy (gallbladder removal) Yes    No
    • hysterectomy Yes    No
    • Cesarean section Yes    No
    • tonsillectomy Yes    No
    • any other surgery:    Yes    No
19. Are you able to walk without help? Yes    No
20. Is there a physician with whom you prefer to be scheduled?     Yes    No if yes, physician name?
21. Do you have a preference of a male or female physician? Male    Female No preference

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 certify that I have answered all questions correctly and completely. I understand that answering any questions incorrectly may impact my health.
• 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.

Insurance Coverage

Please provide the details of the insurance you anticipate that you will use for this procedure. Please include all information, including plan name, that is noted on your card.

Primary Insurance Co.
ID:
Group Number:

Secondary Insurance Co.
ID:
Group Number:

Please note: If your insurance information changes after you are scheduled but before the procedure, it is imperative that you call our office to alert us to avoid potentially charges.

 

 

Would you like a copy of your submission for your records?    Yes    No If yes, please provide an email address

HIPAA AUTHORIZATION FOR USE OR DISCLOSURE
OF HEALTH INFORMATION

Patient Name:
Date of Birth:

to use or disclose the following health information:
All of my health information
My health information relating to the following treatment or condition:

The above party may disclose this health information to the following recipient:

Gastrointestinal Associates, Inc.
1095 Rydal Road, Suite 100
Jenkintown, PA 19046
Ph: 267.620.1100
Fax: 215.572.1279

I understand that this authorization will remain in effect until the provider fulfills this request.

I understand that I may revoke this authorization by sending notification, in writing, to the following:

 

Alfreda Rawlings, Privacy Officer
1095 Rydal Road, Suite 100
Jenkintown, PA 19046