Overview

Open Access Colonoscopy allows healthy patients, without exclusion criteria, to receive a screening colonoscopy without an initial office visit.

Colonoscopy screening is a test for early diagnosis of common cancers before symptoms develop.

Colorectal cancer is the second leading cause of cancer related deaths a 5 - 6 percent lifetime risk.

The current recommendation for colon cancer screening by the American Cancer Society is a colonoscopy starting at the age of 45. Future examinations are planned based on the findings.

 

Exclusion criteria list includes:

• Anticoagulants (blood thinner) / Antiplatelets / clotting diathesis
• Multiple or unstable co-morbidities (having one or more additional  diseases)

o Unstable cardiac disease, pacer/defibrillator, endocarditis, recent myocardial infarction (MI)

o Steroid-dependent pulmonary disease, sleep apnea, or use of a CPAP

o Renal distress, dialysis

o Neurologic disorders

• Unstable cardiac disease, pacer/defibrilator, endocarditis, recent myocardial infarction (MI)
• Oxygen or steriod dependent pulmonary disease, sleep apnea or CPAP
• Renal distress, dialysis
• Neurological disorders
• Extensive abdominal surgery
• GI bleeding, change in bowel movements, weight loss, bleeding
• Chronic narcotic use for pain control
• Insulin dependent diabetes
• Previous problems with anesthesia
• Age > 80
• Overweight

 

To begin this process, please complete the questionnaire and email to Marie@texasliver.com 

Liver Specialists of Texas. LLC

6560 Fannin Street Suite 2050

Houston, Texas 77030

713-794-0700

 

Please allow two weeks for the paperwork to be processed.

Paperwork needs to be filled out in its entirety or it will not be processed.

Please provide a copy of recent lab work.

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Questionnaire

Patient Name: _____________________________Date of Birth: ________________
Phone: ________________________ Height:________________ Weight: ____________

 

Primary Care Physician:

____________________________________________________

 

GI Symptoms:

o None
o Poor appetite o Bleeding o Polyps / Diverticulosis
o Weight loss o Nausea / vomiting o Change in bowel pattern
o Difficulty swallowing o Abdominal pain o Heartburn

 

Past Medical History:

o None
o Anemia o Sleep apnea o Seizure o Cancer o Diabetes
o Stroke o Crohn’s disease o Blood clotting problems o DVT / PE o Diverticulitis
o Heart problems o MRSA or VRE o Liver disease / Hepatitis o Hypertension
o Ulcerative colitis o High cholesterol o Polyps o Kidney disease
o Lung problems o Endocarditis o TB

 

Previous Procedure / Surgical Information:

o EGD / Colonoscopy –

Where:_____________________________________________

Date: ______________________________________________
o Gastric bypass / Abdominal surgery – Explain: _______________________________________
o Previous surgeries (general, orthopedic, etc) – Explain: _________________________________

 

Medications:

Please attach list of medications, vitamins and aspirin products or blood thinners
o Aspirin or aspirin products o Lovenox o Eliquis
o Vitamins o Coumadin (warfarin) o None
o Plavix o Pradaxa o Other
o Xarelto o NSAID (Celebrex, ibuprofen, naproxen,Toradol, Lodine, Indocin)

 

Allergies:

_________________________________________________________________

 

History: Family / Social 

o Colon cancer o Polyps o Tobacco o Alcohol
Symptoms: o Fever o Bleeding problems o Breathing difficulties
o Chest pain o Lightheadedness / Fainting o None

 

Patient Signature

________________________________________

 

Provider Signature

________________________________________