Direct Access Colonoscopy

1
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2
Have you previously been seen by or had a procedure with Dr. Ken Nguyen, Dr. Tim (Tien-Chun) Chen, Dr. Dana Pan* This field is required.
YESNO
3
Do you currently have any of the following GI symptoms?* This field is required.1) Unexplained abdominal pain 2) Uncontrolled heartburn 3) Rectal bleeding or blood in your stool 4) Unexplained nausea/vomiting 5) Chronic unexplained diarrhea 6) Unintentional weight loss 7) Difficulty swallowing
YESNO
4
Are you on any of the following blood thinner medications?* This field is required.1) Coumadin (warfarin) 2) Plavix (clopidogrel) 3) Xarelto (rivaroxaban) 4) Eliquis (apixaban) 5) Pradaxa (dabigatran) 6) Effient (prasugrel) 7) Lovenox (enoxaparin)
YESNO
5
Do you have any of the following medical conditions?* This field is required.1) Chronic obstructive pulmonary disease (COPD) 2) Congestive heart failure (CHF) 3) Morbid obesity with a body mass index (BMI) ≥ 45 4) Heart attack or heart stent placed within the last 1 year 5) Pulmonary embolism (PE) or deep vein thrombosis (DVT) within the last 6 months 6) Unexplained anemia
YESNO
6
Unfortunate, you're not qualified!

Based on your symptoms or medical conditions, it is recommended that you schedule an office consultation with one of doctors first before scheduling your colonoscopy. Use the link below to schedule an appointment online:

SCHEDULE AN APPOINTMENT
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26
Primary Insurance Type* This field is required.***NOTE: Optum is the ONLY HMO/IPA we accept for direct access colonoscopy. If you have another HMO/IPA or if your insurance is not listed, please call our office first to schedule a consultation.***
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27
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Is the referring provider also your primary care provider (PCP)?* This field is required.
YESNO
49
Do you have a primary care provider (PCP)?* This field is required.
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50
PCP's Name* This field is required.
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51
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Other
Country
52
Has your medical history changed since your last visit?* This field is required.
YESNO
53
Have you had a colonoscopy before?* This field is required.
YESNO
54
How recent was your last colonoscopy?* This field is required.
less than 1 year ago
1-2 years ago
3-5 years ago
6-9 years ago
10 years ago
more than 10 years ago
Other
55
Name of the doctor who perform your last colonoscopy* This field is required.
Dr.
Dr.
NP
PA
Other
Prefix
First Name
Last Name
56
Result of Last Colonoscopy* This field is required.If known, please specify that type of colon polyps that were found on your previous colonoscopies.
Normal
Polyp(s)
Hemorrhoid
Diverticulosis
Colon Cancer
Don't remember
Poor Preparation
Other
57
Have you ever had any polyps found during any of your previous colonoscopies?* This field is required.
YESNO
58
Types of Colon Polyps* This field is required.If known, please specify that type of colon polyps that were found on your previous colonoscopies.
Hyperplastic Polyps
Adenomas
Sessile Serrated Adenomas
Inflammatory Polyps
Don't Know
59
Do you have a personal history of colon cancer?* This field is required.
YESNO
60
Do you have a family history of colon cancer?* This field is required.
YESNO
61
Family Members with Colon Cancer* This field is required.Please list any known family members with colon cancer. Click "SAVE" after each new entry.
62
Past GI Medical History - Esophagus* This field is required.Do you have any of the following GI-related medical problems of the esophagus?
None
Heartburn/GERD/Acid Reflux
Barrett's Esophagus
Reflux Esophagitis
Eosinophilic Esophagitis
Esophageal Stricture or Narrowing
Achalasia
Esophageal Spasm
Esophageal Cancer
Zenker's Diverticulum
Other
63
Past GI Medical History - Stomach* This field is required.Do you have any of the following GI-related medical problems of the stomach?
None
Stomach Cancer
Gastric Ulcer
Gastrointestinal Bleeding
H. Pylori Infection
Gastroparesis
Gastritis
Other
64
Past GI Medical History - Small/Large Intestine* This field is required.Do you have any of the following GI-related medical problems of the small or large intestine?
None
Crohn's Disease
Ulcerative Colitis
Irritable Bowel Syndrome (IBS)
Colon Polyps
Colon Cancer
Diverticulosis
Diverticulitis
Chronic Constipation
Chronic Diarrhea
Duodenal Ulcer
Celiac Disease
Microscopic/Collagenous Colitis
Other
65
Past GI Medical History - Anorectal* This field is required.Do you have any of the following GI-related medical problems of the anus or rectum?
None
Hemorrhoid
Anal Fissure
Anal Fistula
Perianal Abscess
Anal Cancer
Anal Wart
Other
66
Past GI Medical History - Liver* This field is required.Do you have any of the following GI-related medical problems of the liver?
None
Abnormal Liver Tests
Hepatitis B
Hepatitis C
Liver Cirrhosis
Liver Cancer
Liver Transplant
Alcoholic Liver Disease
Fatty Liver Disease/NASH
Other
67
Past GI Medical History - Pancreas/Gallbladder* This field is required.Do you have any of the following GI-related medical problems of the pancreas or gallbladder?
None
Acute Pancreatitis
Chronic Pancreatitis
Pancreatic Cancer
Gallstones
Cholecystitis
Gallbladder Cancer
Cholangiocarcinoma
Other
68
Other Past Medical History* This field is required.Do you have any of the following non-GI medical problems?
None
Diabetes
High Blood Pressure
Coronary Artery Disease
Heart Attack
Heart Failure
Heart Valve Problem or Murmur
Atrial Fibrillation/Atrial Flutter
Abnormal Heart Rhythm
Peripheral Vascular/Arterial Disease
Blood Clots in Vein (DVT or PE)
COPD
Sleep Apnea
Asthma
Chronic Kidney Disease
End-stage renal disease (Dialysis)
Non-GI Cancer
Anemia
Bleeding Disorder
Morbid Obesity (BMI >40)
Endometriosis
HIV
Stroke/TIA
Drug/Chemical Dependent
Anxiety
Depression
Other
69
Past Surgical/Procedure History* This field is required.Have you have any of the following surgeries or procedures done?
None
Gastric bypass/Weight loss surgery
Colon Resection
Cholecystectomy (Gallbladder)
CABG (Coronary Artery Bypass)
Heart Valve Surgery
Coronary Stents Placement
Pacemaker/Defibrillator Placement
Peripheral Vascular Bypass
Hysterectomy
Kidney Transplant
Liver Transplant
Whipple's
Small Bowel Resection
Ileostomy or Colostomy
Hemorrhoid Surgery or Banding
Hernia Repair
Other
70
Do you drink more than 5 drinks of alcohol per week?* This field is required.
YESNO
71
Are you currently taking any medications?* This field is required.
YESNO
72
Do you consent for us to obtain your medication history from your pharmacy?* This field is required.
YESNO
73
Current MedicationsPlease list all medications you're currently taking. Note: click "SAVE" after each new entry.
74
Do you have any drug or non-drug allergies?* This field is required.
YESNO
75
Allergies* This field is required.Please list all allergies and their reactions. Click "SAVE" after each new entry.
76
Cancellation/Financial Policy & Procedure Billing Information* This field is required.CANCELLATION POLICY If you need to cancel or reschedule your procedure, please do so at least 3 business days in advance. Otherwise, you may be charged a $200 cancellation fee if you cancel/reschedule late or do not show up for your procedure without a valid excuse. PROCEDURE BILLING When undergoing a procedure by our doctors, you may receive up to 4 separate bills: 1) from our doctors performing the procedure 2) from the facility (surgery center or hospital) where your procedure is done 3) from the anesthesiologist or nurse anesthetist if your procedure is done with anesthesia 4) from the pathology lab if you have any biopsy taken By clicking below, you acknowledge that you received, read, and agree to our Cancellation/Financial Policy & Procedure Billing Information.
77
Notice of Privacy Policy* This field is required.This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review the information carefully by clicking on the link below. By checking the box below, you acknowledge receiving the Notice of Privacy Practices.
78
Signature* This field is required.
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