• Bergen New Bridge Medical Center - Paramus, New Jersey 07652

  • Direct Access Colonoscopy Qualification Questionnaire

  • Our Direct Access Colonoscopy Program allows eligible patients to schedule a screening colonoscopy without a separate pre-procedure office visit. By completing this form, you may qualify for direct scheduling and avoid delays caused by extra appointments. We realize that some patients are more comfortable meeting the physician prior to the procedure. If you would prefer to schedule an in-person consultation to discuss colonoscopy for colon cancer screening, please indicate that at the end of this form or contact our GI office. Our staff is ready to answer your questions and support you through every step of the process.

  • Bergen New Bridge Medical Center - Paramus, New Jersey 07652

  • Direct Access Colonoscopy Qualification Questionnaire

  • Demographic Information

  • Date of Birth*
     / /
  • Format: (000) 000-0000.

  • Insurance/PCP/Pharmacy Information

  • Medical History

  • 1. Do you have any current gastrointestinal symptoms?*
  • 4. Do you currently smoke cigarettes or consume alcohol excessively?*
  • 5. Do you have a family history of colon cancer?*
  • 7. Do you have any allergies to medications?*
  • Image field 72

  • Bergen New Bridge Medical Center - Paramus, New Jersey 07652

  • Direct Access Colonoscopy Qualification Questionnaire

  • Questionnaire

  • 1. Are you 75 years or older?*
  • 2. Are you pregnant or possibly pregnant?*
  • 3. Are you being treated for a heart condition such as: heart attack in the past year; heart failure; heart valve problem; heart stent; abnormal heart rhythm or atrial fibrillation; or other heart conditions?*
  • 4. Do you have a heart device such as a pacemaker or a defibrillator?*
  • 5. Other than routine aspirin use, are you taking any other blood thinners such as: Coumadin/Warfarin, Lovenox, Plavix/Clopidogrel, Effient/Prasugrel, Brilinta/Ticagrelor, Pletal/Cilostazol, Xarelto/Rivaroxaban, Pradaxa/Dabigatran, Eliquis/Apixaban, etc.?*
  • 6. Are you taking any of the following GLP-1 receptor agonist medications: Semaglutide (Ozempic, Rybelsus, Wegovy), Liraglutide (Saxenda, Victoza), Dulaglutide (Trulicity), Exenatide (Byetta, Bydureon), Tirzepatide (Mounjaro, Zepbound), etc.?*
  • 7. Are you being treated for an advanced lung condition or do you use oxygen at home?*
  • 8. Are you being treated for kidney failure or receiving dialysis?*
  • 9. Do you have advanced liver disease (cirrhosis)?*
  • 10. Have you had a stroke or seizure in the past year?*
  • 11. Have you had an organ transplant?*
  • 12. Do you have any medical problems that are currently difficult to control?*
  • 13. Have you been treated for acute diverticulitis in the past 2 months?*
  • 14. Do you have Ulcerative Colitis or Crohn’s disease?*
  • 15. Do you have iron deficiency anemia or blood in the stool?*
  • 16. Did your doctor recommend a colonoscopy because of gastrointestinal symptoms or abnormal GI test results?*
  • 17. Do you have any current gastrointestinal symptoms that need to be addressed with the gastroenterologist prior to the procedure?*
  • 18. Do you have a history of severe constipation or inadequate bowel prep for a previous colonoscopy?*
  • 19. Have you had difficulty with sedation or anesthesia during previous procedures?*
  • 20. This program allows you to bypass the pre-procedure office visit. You will briefly meet the gastroenterologist on the day of your colonoscopy. Would you prefer an in-person consultation in the office prior to scheduling?*

  • Bergen New Bridge Medical Center - Paramus, New Jersey 07652

  • Direct Access Colonoscopy Qualification Questionnaire

  • Please upload a picture of the front and back of your insurance card below.

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  • Bergen New Bridge Medical Center - Paramus, New Jersey 07652

  • Direct Access Colonoscopy Qualification Questionnaire

  • Benefits: Colonoscopy is a proven, life-saving procedure used to screen for and prevent colorectal cancer, the second leading cause of cancer-related death in the U.S. The procedure involves the use of a flexible camera to examine the colon and rectum. Prior to the procedure, the patient undergoes a cleansing bowel preparation to maximize the effec- tiveness of the test. Most patients experience little to no discomfort due to conscious sedation anesthesia. If polyps or abnormalities are found, they can usually be removed during the procedure, reducing cancer risk.

    Risks: A colonoscopy is generally a very safe procedure that can be lifesaving; however, as with all medical procedures, there are some potential risks involved. These risks include bleeding, infection, missed abnormalities, colon perforation requiring repair, and adverse reactions to sedation. These complications are rare and are generally outweighed by the benefits of early cancer detection and prevention.

    By submitting this form, I acknowledge that I have answered the questions to the best of my ability, and that I have read and understand the stated risks and benefits related to the colonoscopy procedure. I understand that the GI team will review my responses and contact me within 5–7 business days regarding next steps.

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