Direct Access Colonoscopy Questionnaire

Answer a few questions to see if you can schedule a screening colonoscopy without an office visit first. It takes about 5 minutes. Your health answers are checked on your device and are not sent to us.

How old are you?

Under 45 45 to 75 Over 75

Do you have any of these right now?

Check all that apply.

Rectal bleeding or blood in your stool Belly pain that hasn’t been explained A change in bowel habits lasting more than a few weeks Weight loss you weren’t trying for Trouble swallowing Heartburn that isn’t controlled Nausea or vomiting that hasn’t been explained Ongoing diarrhea or constipation A recent positive stool test (Cologuard or FIT) None of these

Do you take a blood thinner?

For example pills such as apixaban (Eliquis), clopidogrel (Plavix), rivaroxaban (Xarelto), warfarin (Coumadin), ticagrelor (Brilinta), dabigatran (Pradaxa), edoxaban (Savaysa), prasugrel (Effient), aspirin-dipyridamole (Aggrenox), or cilostazol (Pletal), or injections such as enoxaparin (Lovenox), dalteparin (Fragmin), fondaparinux (Arixtra), or heparin. Aspirin alone doesn’t count.

No Yes

Do you have any of these health conditions?

Check all that apply.

Heart attack or heart stent in the last year Congestive heart failure Blood clot in the lungs (PE) or legs (DVT) in the last 6 months Severe COPD or another serious lung disease Use oxygen at home Severe sleep apnea Kidney failure on dialysis Use a wheelchair full-time Cirrhosis or severe liver disease Crohn’s disease or ulcerative colitis A bleeding or clotting disorder None of these

What is your height and weight?

We use this to check that sedation is safe in an outpatient center.

US (ft, in, lb) Metric (cm, kg)

Height (feet) Height (inches) Weight (pounds)

Height (cm) Weight (kg)

What insurance do you have?

PPO or EPO plan (Aetna, Anthem Blue Cross, Blue Shield, Cigna, UnitedHealthcare, and others) Medicare (Original Medicare or a Medicare PPO) Optum Medical Group Regal or Lakeside Medical Group A different HMO or medical group Medi-Cal No insurance or not sure

Can someone drive you home after your colonoscopy?

You will receive sedation and cannot drive, take a taxi, or use a rideshare alone afterward.

Yes No

Good news: you qualify for Direct Access Colonoscopy

Tell us how to reach you. Our team will call within 1–2 business days to schedule and send your prep instructions.

First name Last name Date of birth Phone Email Preferred doctor

Primary care or referring provider (optional)

Pick your doctor from the list, or just type the name.

Preferred pharmacy

We’ll use this to send your prep prescription. You can change it when we call.

Which Chinese language do you speak?

Mandarin Cantonese Both Mandarin and Cantonese

Company

I agree to be contacted by phone, text, or email about scheduling my colonoscopy.

An office visit is the best next step

Based on your answers, a gastroenterologist should see you before a colonoscopy.

Taking you to our appointment page in 8 seconds…

Schedule an Office Visit Call 626-898-4560

Thank you! We received your request.

Our team will call you within 1–2 business days to schedule your colonoscopy at Valley Digestive Health Center in Arcadia and send your prep instructions.

We've also sent a confirmation to your email. If you don't see it, check your spam folder.

Questions? Call 626-898-4560.

This questionnaire is not medical advice. If you have severe symptoms or an emergency, call 911.

Unio Specialty Care - Temple City

Gastroenterology & Hepatology

6271 Rosemead Blvd
Temple City, CA 91780

Tel: 626.898.4560
WhatsApp: 626.898.4560
Email: templecity@uniohp.com

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