21 Jefferson Place, Athens, GA 30601

(706) 548-0058 706-548-0555

Athens Gastroenterology Center

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Colonoscopy Direct Procedure Candidacy Questionnaire

Colonoscopy Direct Procedure

Candidacy Questionnaire

Please complete this form before your consultation. Your responses will help determine if a colonoscopy direct procedure is the best treatment option for you.

Patient Request for GI Appointment

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Patient Information

Full Name:

Date of Birth

Phone Number:

Email Address:

Primary Care Physician (if any):

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Eligibility Assessment

1. Reason for Colonoscopy (select all that apply)

Routine screening (ages 45+)

Family history of colon cancer/polyps

Personal history of colon polyps

Positive FIT/FOBT test

Change in bowel habits

Rectal bleeding

Abdominal pain

Unexplained weight loss

Other:

If other, please explain:

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2. Medical History

Have you ever been diagnosed by any of the following? (Select all that apply)

Heart disease (e.g., stents, heart failure, valve disease)

Lung disease (e.g., COPD, asthma requiring regular meds)

Kidney disease or on dialysis

Liver disease (e.g., cirrhosis, hepatitis)

Diabetes requiring insulin

Sleep apnea (using CPAP or not diagnosed)

Bleeding disorders or on blood thinners

History of complications with anesthesia or sedation

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3. Medications

Are you currently taking any of the following?

Blood thinners (e.g., Plavix, Eliquis, Xarelto, Warfarin)

Diabetes medications (e.g., insulin, GLP-1 agonists)

Aspirin or NSAIDs daily

Iron supplements

Herbal supplements

4. Past Surgical History

Prior colonoscopy complications

Colon surgery or bowel resection

Bariatric (weight loss) surgery

Abdominal surgeries (e.g., hysterectomy, appendectomy)

None

5. Allergies

6. Functional Status

Able to walk without assistance

Lives independently

No major physical limitations

7. COVID or Infection Screeing

No symptoms of recent illness, fever, cough

No recent exposure to communicable disease

No known MRSA, VRE, or C. diff

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Patient Attestation

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By checking this box, I confirm that the above information is accurate. I understand that this form will be reviewed to determine if I can proceed with a colonoscopy without an in-person visit. I may be contacted for more information or scheduled for a pre-procedure consultation if necessary.

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Athens Gastroenterology Center

Our center of excellence also provides a Quad A certified Ambulatory Surgical Center for endoscopy.

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Address: 21 Jefferson Pl, Athens, GA 30601, USA

Phone: (706) 548-0058

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