Easy Access Colon Cancer Screening Form

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  • Please select Yes or No in answer to the following medical questions.

    If you answer “Yes” to any of the questions below, you must have an office visit.
  • Do you have heart problems (chest pain, heart attack, heart stents, heart failure, valve problems/replacement, bypass surgery, atrial fibrillation or other irregular heart beat or history of stroke? *
  • Do you take blood thinners other than aspirin (i.e. Coumadin, Pradaxa, Plavix, Effient, Eliquis, Xarelto, Aggrenox)? *
  • Do you have a pacemaker or defibrillator? *
  • Do you have severe sleep apnea or other breathing problems (COPD, emphysema, asthma) that require oxygen or steroid pills? *
  • Do you have kidney failure? *
  • Have you had problems with: sedation/anesthesia, opening your mouth/breathing tubes? *
  • Do you have black stools or blood in your stools? *
  • Have you been diagnosed with a bleeding disorder or anemia?* *
  • Do you have upper abdominal pain, uncontrolled heartburn, or difficulty swallowing? *
  • Do you have unexplained weight loss greater than 10 lbs in the last month? *
  • Do you have poorly controlled or insulin dependent diabetes? *
  • Do you have any other ongoing illness that you feel you need to have an office visit for prior to scheduling the procedure? *
  • Do you have first degree relatives (mother, father, brother and sister) with colon cancer? *
  • Have you had a colonoscopy previously? *
  • Do you have allergies to medications, eggs or latex? *
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    Body mass index (BMI)*

    (If BMI is over 40 you will need an office visit prior to scheduling.)

  • I have read and understand the following forms and wish to proceed *
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You are not eligible for Easy Access Colonoscopy.
Please contact us to schedule a consulation.