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DIRECT ACCESS SCREENING INTAKE FORM

Direct Access Colonoscopy

Eligible patients may be able to receive a screening colonoscopy without a pre-procedure visit. Please answer a few questions to see if you qualify (survey below).

Patient Name

Primary Phone

DOB

Alt Phone

Insurance Name

Subscriber

Policy No

Group #

PCP

Phone Number

Pharmacy

Phone Number

Screening Questionnaire (Any YES response from the questions below excludes patient from DASC)

Do you have any of the following symptoms: Rectal bleeding, change in bowel habits, abdominal pain, unintentional weight loss?

Do you have any of the following symptoms: Rectal bleeding, change in bowel habits, abdominal pain, unintentional weight loss?
A
B

Do you currently have any nausea/ vomiting, uncontrolled heartburn, difficulty swallowing, or upper abdominal pain?

Do you currently have any nausea/ vomiting, uncontrolled heartburn, difficulty swallowing, or upper abdominal pain?
A
B

Do you take any blood thinning medications? (Pradaxa, Eliquis, Xarelto, Lovenox, Coumadin, Aggrenox, Brilinta)

Do you take any blood thinning medications? (Pradaxa, Eliquis, Xarelto, Lovenox, Coumadin, Aggrenox, Brilinta)
A
B

Are you less than 45 years old or older than 75 years old?

Are you less than 45 years old or older than 75 years old?
A
B

Are you on home O2, dialysis, or diagnosed with chronic kidney disease (stage3&up)?

Are you on home O2, dialysis, or diagnosed with chronic kidney disease (stage3&up)?
A
B

Have you had a recent heart attack or cardiac intervention/stent placement or stroke in the past 12 months

Have you had a recent heart attack or cardiac intervention/stent placement or stroke in the past 12 months
A
B

Do you have CHF or uncontrolled diabetes, seizure/epilepsy?

Do you have CHF or uncontrolled diabetes, seizure/epilepsy?
A
B

Do you have chemo or radiation in the last 6 months?

Do you have chemo or radiation in the last 6 months?
A
B

Do you have a pacemaker/defibrillator?

Do you have a pacemaker/defibrillator?
A
B

Did you have a positive home stool test or Cologuard test in the last 3 years

Did you have a positive home stool test or Cologuard test in the last 3 years
A
B

Is your weight greater than 350 lbs?

Is your weight greater than 350 lbs?
A
B

Do you take any GLP-1 or Sglpt-2 meds? (Ozempic, Trulicity, Jardiance, Wegovy)

Do you take any GLP-1 or Sglpt-2 meds? (Ozempic, Trulicity, Jardiance, Wegovy)
A
B

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