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.

Please complete the following questionnaire and submit online.

• Open Access Colonoscopy at our institution is approved for patients age 50 to 70 in good health.

  a. How old are you now?
  
  

  Those who desire colon cancer screening below age 50 or above age 70 are encouraged to schedule an office visit to determine if screening is medically appropriate.

• Have you had a colonoscopy in the past?    Yes    No
  
  • If the answer is yes, please provide the name and phone number of the physician who performed the procedure, as well as the date.
    
  • If the procedure was not done by Gastrointestinal Associates, please obtain a copy of the procedure report and any biopsy results. We cannot schedule open access colonoscopy without this information.
• If colonoscopy was recommended because of family history of colon cancer or polyps, which relative had cancer or polyps and how old were they?
  
• Do you have any gastrointestinal symptoms such as abdominal pain, bleeding, weight loss, difficulty swallowing, frequent diarrhea    Yes    No

• 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
  • 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
• Are you taking any medications for High Blood Pressure? Yes    No
• Do you experience chest pain or shortness of breath? Yes    No
• Do you: Smoke? Yes    No
• Drink alcohol? Yes    No
• Use any illicit drugs? Yes    No
• Alcohol intake Daily    Weekly    Monthly
• Do you have any medication allergies? Please list.
  
• Do you take any blood thinners other than aspirin? Yes    No
• List all medications that you take including herbals and over the counter medications:
  
• Have you had difficulty with anesthesia other than nausea? Yes    No
• Have you had Colon Surgery? Yes    No
• 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:
• Are you able to walk without help? Yes    No
• What is your height?
• What is your weight?

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.
PATIENT REGISTRATION

Welcome to our practice. Please complete all sections of this registration form. Thank you.

Patient Information

Last Name:
First:
MI:

Address:
Apt.#

City:
State:
Zip Code:

Sex: Male  Female Marital Status: Single  Married  Other Student: FT    PT    N/A

Employed By:

Email Address:
Cell Phone#

Home Phome#
Work Phone#

Date of Birth:

Emergency Contact Name:

Relation:
Phone#

Federal Government Requirement: Race:
Language Spoken:

Ethnicity Circle: Hispanic or Latino    Non-Hispanic or Non-Latino

Pharmacy Name, Address, Phone#, Fax#:

Mail Order Pharmacy Name, Address, Phone#, Fax#:

PLEASE BRING ALL MEDICINE BOTTLES TO YOUR APPOINTMENT

Referral Information

Primary Care Physician:

Address :
Telephone:

Insurance Company Information

Patient’s Relationship to Insured Party (Circle One):
Self   Child   Wife   Husband   Other

Primary Insurance Co.
ID#

Secondary Insurance Co.
ID#

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.

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