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Open Access Program Online Form
Open Access Colonoscopy Program Medical Questionnaire
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
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California
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Connecticut
Delaware
District of Columbia
Florida
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Idaho
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Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
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New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone (Day)
Phone (Mobile)
*
Date of Birth
*
Referring or Primary Care Provider
*
If no referring or primary care provider, please write “none.”
First
Last
Referring or Primary Care Office
*
Please list the name of the practice. If you do not have a referring or primary care office, write “none.”
Height
*
Weight
*
Insurance Carrier
*
Member ID
*
Group ID
*
Insured Name
*
First
Last
Relationship
*
Ins. Cust. Serv. Tel #
*
Location Requested
*
Physician Requested
*
First
Last
Payment Method
*
Self-Pay
No Insurance
Insurance
Who are we allowed to contact in the event you are unavailable?
Name
First
Last
Relationship
Re: Procedure Confirmation & HIPAA Compliance
Please list any active medical problems
*
Please list all medications including vitamins, prescription, and non prescription (include over the counter products) include dosage/frequency, strength and last taken
*
It is important that patients 65 and older have a history and physical on file with their primary care physician within 30 days of their Open Access Colonoscopy. This can easily be obtained through your primary care provider.
Have you met that criteria?
*
Yes
No
Date of exam
*
MD
*
Do you take blood thinning medication? (Coumadin, aspirin, or plavix)
*
Yes
No
Do you have any allergies to medications?
*
Yes
No
Please list and the reaction:
*
Please check Yes or No in answer to the following medical history questions.
Heart Disease
Coronary Artery Disease / Angina / Heart Attack
*
Yes
No
Congestive Heart Failure
*
Yes
No
Valvular Heart Disease / Artifical Heart Valve
*
Yes
No
Lung Disease
Emphysema, COPD, Asthma, or Bronchitis requiring regular medical therapy
*
Yes
No
Sleep Apnea
*
Yes
No
General Health
Kidney Disease
*
Yes
No
Stroke
*
Yes
No
Diabetes
*
Yes
No
Do you take antibiotics when going for dental work?
*
Yes
No
Have you had a joint replacement within the last year?
*
Yes
No
Have you ever had a complication with anesthesia?
*
Yes
No
Do you weigh more than 350 pounds?
*
Yes
No
Gastroenterology
Do you have heartburn more than twice a week?
*
Yes
No
Do you see blood in your bowel movements?
*
Yes
No
Do you have frequent constipation or diarrhea
*
Yes
No
Do you have relatives with colon cancer?
*
Yes
No
Who
Have you ever had a colonoscopy?
*
Yes
No
If yes, when?
Upon clicking Send, this form will be sent to Charlotte Gastroenterology & Hepatology for processing. If there are no contraindications, you will be assigned to one of our physicians and scheduled for a colonoscopy. If medical concerns are identified, we may need to schedule an office visit before scheduling a colonoscopy. Your insurance company will be notified for benefit verification. We will contact you within 10 days of receipt of this form. If you have not heard from our office within 10 days, please call (704) 717-5548 and ask for the Open Access Triage Coordinator.
After completing this 'Open Access Medical Questionnaire form' please complete the 'open access patient registration form'