Direct Access Colonoscopy Patient Questionnaire

Direct Access Colonoscopy Patient Questionnaire
Patient Information
Name

First Name, MILast Name
Date of Birth*

MonthDayYear
Last Four of Social*
Sex*

MaleFemale
Marital Status*
Race*
Preferred Language*
Height*
Weight*
Employer*

0/100
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*

Provide county in which you live.0/100
Email*
example@example.com
Home Phone*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Emergency Contact
Name*

First NameLast Name
Relationship*
Phone Number*
Please enter a valid phone number.
Referring Physician
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Primary Care Physician
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Preferred Pharmacy
Name*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Insurance
Check here if uninsured and would like to discuss payment options.

Contact me to discuss payment options
Name of Insurance*
Precertification Phone Number*
Please enter a valid phone number.
Claims Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Number*
Group Number*
Policy Holder's Name*
Relationship*
Last Four of Social*
Date of Birth*

MonthDayYear
Date
Employer*
Secondary Insurance
Name of Insurance
Precertification Phone Number
Please enter a valid phone number.
Claims Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Number
Group Number
Policy Holder's Name
Relationship
Last Four of Social
Date of Birth

MonthDayYear
Date
Employer
Medical History

Do you have persistent or recurring problems, or history of the following?
Is this your first colonoscopy?*

YesNo
Has it been 10 years since your last colonoscopy?*

YesNo
Are you on any blood thinners?*

YesNo
Have you recently had a physical exam?*

YesNo
Are you a dialysis patient?*

YesNo
Do you have congestive heart failure?*

YesNo
Do you have ischemic heart disease?*

YesNo
General
Do you have persistent or recurring problems, or history of the following?

DizzinessFatigueFeverWheelchair BoundUnexplained Weight LossUnexplained Weight Gain
How many pounds lost?
How many pounds gained?
GI
Do you have persistent or recurring problems, or history of the following?

Abnormal PainConstipationDiarrheaNauseaHeartburn/RefluxDifficulty/Painful SwallowingVomitingRectal Bleeding/Blood in StoolUlcerative ColitisChron'sLiver DiseaseIntestinal surgery in the last 6 monthsHave you ever had a colonoscopy?Have you ever had polyps or colon cancer?Any Relatives with colon cancer/polyps?
What? & When?
Where? & When?
Who and what age were they?
Hematologic
Do you have persistent or recurring problems, or history of the following?

Anemia (recent treatment)Free Bleeder/HemophiliacTake any Blood Thinners such as Plavix, Coumadin, Warfarin, Effient, Lovenox, etc.
Neurologic
Do you have persistent or recurring problems, or history of the following?

Stroke/TIASeizure
When was your last Stroke/TIA and do you have any weakness leftover?
When was your last seizure?
Cardiovascular
Do you have persistent or recurring problems, or history of the following?

Chest Pain/Pressure/HeavinessIrregular Heart RhythmHigh Blood PressureBypassValve Surgery
When was your Bypass?
ENT
Do you have persistent or recurring problems, or history of the following?

Hard of HearingUnexplained Vision ChangesGlaucoma
Genitourinary
Do you have persistent or recurring problems, or history of the following?

Kidney disease/failureDiabetesInsulinOral MedsDialysis
What kind of dialysis?
Psychological
Do you have persistent or recurring problems, or history of the following?

DepressionAnxiety/Panic AttacksDementia/Memory LossOther Mental Illness
What kind of mental illness?
Respiratory
Do you have persistent or recurring problems, or history of the following?

Sleep ApneaShortness of BreathAsthma (recent treatment)COPD/Emphysema/Chronic BronchitisOn Oxygen
How many liters and when?
Other Medical History
Have you been hospitalized within the last month: Why?
Have you ever had problems with anesthesia? Please describe.
Have you ever had an organ transplant? What and When?
Other Medical History
Previous Surgeries and Dates
Have you had any surgeries?*

YesNo
Provide all surgeries and dates below.
Allergies to Medications, Food, or Latex
Do you have any allergies?*

YesNo
Name all allergies and reactions below.
Medications
Prescription or over the counter including vitamins, etc.*

YesNo
Provide the following information on all prescriptions, over the counter drugs, and vitamins you take below. *
Benefits and Risks
Benefits: A colonoscopy is the most accurate way to find and remove polyps, which carries the potential to grow into cancer.

Risks: Some of the common risks associated with colonoscopy is mentioned below.

The Risks

Perforation of the intestine
A hole made by pressure from the scope that passes through the entire wall of the colon is a rare complication reported in less than 1 of 1,000 cases.

Keeping you informed:
- A large perforation noticed immediately may require surgery.
- A small perforation noticed the first few days after the procedure may be treated with rest, fluids, antibiotics, and close observation.
Bleeding
Bleeding is reported in 0 to 6 of 1,000 procedures. The risk is increased when many or a large polyp is removed.

Keeping you informed:
- A small amount of bleeding may occur after colonoscopy.
- Call your doctor if you notice more amount of bleeding or persistent bleeding after colonoscopy.
Cardiorespiratory
Minor Changes in oxygen levels and heart rate occur in less than 1 of 100 cases.

Keeping you informed:
- The majority of these events are related to sedation and increase with advanced age and other diseases.
All Complications
Approximately one third of patients reports minor symptoms such as bloating, indigestion, abdominal discomfort after colonoscopy, but serious complications are uncommon.

Keeping you informed:
- Checking for any problems with medication and sedation and monitoring before, during, and after the procedure will reduce risks.
Note: There are several other rare complications involved with the colonoscopy, which are not mentioned above.

References:

American College of Gastroenterology Guidelines for Colorectal Cancer Screening 2008. Douglas K. Rex et al. Am J Gastroenterology 2009; 104:739 - 75.
Complications of colonoscopy. ASGE Standards of Practice Committee. Fisher et al. Gastrointest Endosc. 2011 Oct;74(4):745-52.
Should be Empty:

Direct Access Colonoscopy Patient Questionnaire

Patient Information

Emergency Contact

Referring Physician

Primary Care Physician

Preferred Pharmacy

Primary Insurance

Secondary Insurance

Medical History

General

GI

Hematologic

Neurologic

Cardiovascular

ENT

Genitourinary

Psychological

Respiratory

Other Medical History

Previous Surgeries and Dates

Allergies to Medications, Food, or Latex

Medications

Benefits and Risks