Direct Access Colonoscopy Questionnaire Need help? Call our office at 770-214-2800. Direct Access Colonoscopy Questionnaire This questionnaire helps determine whether you may be eligible to schedule a colonoscopy without a prescreening office visit. It takes about 10 minutes. Please answer every question as accurately as possible. Staff will review your responses before eligibility is confirmed.First Name *Last Name *Best phone number *Phone type *CellHomeWorkDate of birth *Enter as MM/DD/YYYY.Email address *Street address *City *State *Please select an optionGeorgiaAlabamaOtherZIP code *Permission and privacyThese confidential health questions help West Georgia Gastroenterology determine the most appropriate next step. Your information will be transmitted for review. See the Privacy Policy.Would you like to continue with the screening questionnaire? *Yes, continueNo, I do not wish to continueYou have chosen not to continue with the screening questionnaire. Your information has not been submitted. You may select “Yes, continue” to proceed, use the Previous button, or close this page.Have you ever had a colonoscopy? *YesNoUnsureDate of your last colonoscopy *Where was your last colonoscopy performed? *Have you ever had a colon polyp removed? *YesNoUnsureHow many full years ago was the polyp removed? *Enter 0 if less than one full year ago.Have you ever been diagnosed with colon or uterine cancer? *YesNoUnsureWhat year were you diagnosed? *What is your current age? *Do you have a first-degree relative—parent, sibling, or child—with a history of colon cancer? *YesNoUnsureHow old was the relative when diagnosed? *Do you have at least TWO second-degree relatives with a history of colon cancer? *Examples include grandparents, grandchildren, aunts, uncles, nieces, nephews, and half-siblings.YesNoUnsureHow old was the first second-degree relative when diagnosed? *How old was the second second-degree relative when diagnosed? *How many second-degree relatives have been diagnosed with colon cancer? *Do you have insulin-dependent diabetes, electrolyte abnormalities, significant kidney disease, or require dialysis? *YesNoUnsureHeight: feet *Height: inches *Current weight in pounds *Calculated BMICalculated automatically from height and weight.How many bowel movements do you typically have during a normal week? *Are you currently experiencing any of the following? *Rectal bleedingDiarrheaAbdominal painAnemia or low blood countsUnintentional weight lossNone of the aboveUnsureHave you had an episode of diverticulitis in the past 6 weeks? *YesNoUnsureDo you have uncontrolled hypertension or high blood pressure? *YesNoUnsureDo you have a history of Crohn’s disease or ulcerative colitis? *YesNoUnsureDo you have a pacemaker, defibrillator, or heart stents? *YesNoUnsureDo you have any active or uncontrolled heart or lung symptoms or medical conditions? *YesNoUnsureHave you had a recent cough, cold, or flu-like symptoms? *YesNoUnsureAre you currently being treated for an infectious disease? *YesNoUnsureAre you taking any prescription blood-thinning medication besides aspirin? *YesNoUnsurePlease list the blood thinner(s). *Are you on supplemental oxygen? *YesNoUnsureCan you walk up a flight of stairs or do yard work without chest pain or shortness of breath? *YesNoUnsureHave you ever been diagnosed with sleep apnea? *YesNoUnsureHave you ever had a heart attack or stroke? *YesNoUnsureHave you ever had any type of neck surgery? *YesNoUnsureHave you ever had difficulties with anesthesia beyond nausea and vomiting? *YesNoUnsureCan you transfer to and from an exam bed without assistance? *YesNoUnsureAuthorization and acknowledgmentPlease review your answers before submitting. This questionnaire does not provide a diagnosis or guarantee direct-access eligibility. Staff will review and verify your information.Authorization and consent *I confirm that the information I provided is accurate and complete to the best of my knowledge. I authorize West Georgia Gastroenterology to review this information and contact me about colonoscopy screening and scheduling. I acknowledge that I have read the Privacy Policy.Stay Connected (Optional)Yes, I would like to receive occasional emails and other communications from West Georgia Gastroenterology about services, health information, news, and updates. I understand I may opt out at any time.Submit Questionnaire
