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Direct Access Colonoscopy

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Einstein’s Direct Access Colonoscopy allows patients to skip the pre-specialist doctor’s visit and schedule a colonoscopy directly. At Einstein Gastroenterology, our dedicated team of fellowship-trained staff want to make preventative screenings as easy as possible for you.
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First Name
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Last Name
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Telephone
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Date of birth

MM/DD/YYYY

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Height and weight
Do you require an interpreter?
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Which location would you like to have your procedure done at?
Do you have any physical limitations?

Emergency Contact

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Name of emergency contact
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Emergency contact number

Allergies

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Do you have any drug allergies?
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Do you have any food allergies?

Conditions and Procedures

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Have you ever had a colonoscopy?
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Have you had a diagnosis of polyps or cancer in your colon?
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Do you have a family history of colon cancer, ulcerative colitis or Crohn's disease?
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Do you have any digestive issues such as abdominal pain, rectal bleeding, weight loss, diarrhea, constipation, anemia, colitis or Chron's Disease?
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Have you ever seen a cardiologist?

Medical History: Have you had any of the following?

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Heart attack, irregular heartbeat, coronary artery bypass or stent placement, stroke, fainting spells, or congestive heart failure?
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Do you take 2 or more blood pressure medications?
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Breathing problems such as COPD, emphysema, asthma, or obstructive sleep apnea, or use home oxygen or CPAP?
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Kidney problems, renal failure, or are you on any form of dialysis?
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Insulin-dependent diabetes?
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Defibrillator, pacemaker, or artificial heart valve?
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Organ transplant or have been evaluated for an organ transplant?
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History of seizures?
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Do you take any blood thinners other than aspirin?
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Have you been told you have a difficult airway or issues with anesthesia?
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Has anyone in your family ever had a problem with anesthesia?
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Have you had abdominal surgery?
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Do you get short of breath when you lie flat?

Please list all medications, vitamins and herbal supplements you are currently taking.

Name of medicine, dose, and frequency
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