Open Access Screening

Patient Name: Account #:
Date of Birth: Email Address:
Referring MD: Address:
 
Phone Number: When to call:

Insurance Provider:
Policy Number:
Telephone Number:
   
Any Special Needs:
Preferred Dates:
Preferred Physician:
Insurance Company:
Policy Number:
Phone Number:
Pharmacy:
Location:

Thank you for your interest in participating in our Screening Colonoscopy Open Access Program. In order to ensure your safety, it is imperative that the information you submit is accurate to the best of your knowledge. The following questions guide you through the criteria for this program. If you prefer, you may schedule an appointment to meet with one of our providers before scheduling your procedure.

Are you allergic to any medications, latex or contrast?

What type of medical problems do you have?
  - Do you have: sleep apnea CPAP Asthma

What surgeries have you had?
  - Have you had any problems with anesthesia or sedation in the past?

Do you drink alcohol on a regular basis?

Amount
Type
Freq

Do you use any street drugs?

Type

Do you smoke?

PPD
Years

Do you have a family history of colon cancer or polyps?

Who
Age of Diagnosis

What medications do you currently take? (Include OTC, Vitamins, Supplements)

Do you take blood thinners?

Name of Drug
Why?

Are you diabetic?

Home glucose values

Do you take Aspirin, Advil, or Goody powders regularly?

Type

Do you have frequent abdominal pain?

Do you have constipation or diarrhea on a regular basis?

Do you see blood in your stool or on the tissue?

Have you had a heart attack or stroke?

Stents placed?
Year

Do you have any heart, lung, or kidney disease?

Explain

Have you had a colonoscopy before?

When
Where
Findings

Weight lbs
Height feet inches

**** Please carefully review information prior to submission****
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