"*" indicates required fields 1Step 12Step 23Step 3 Let’s get started with a few questions about your digestive health.Have you ever had a colonoscopy?* Yes No When did you have a colonoscopy?* Within the last 5 years Over 5 years ago Have you ever had a colon polyp removed?* Yes No Have you or a close family member (like a parent, brother, sister, or child) ever had colon cancer?* Yes No Have you ever completed a Cologuard® test and received a positive test result?*Have you ever completed a Cologuard® test and received a positive test result? Yes No Do you have kidney disease requiring any form of dialysis?* Yes No Do you have a history of either Crohn’s disease or ulcerative colitis?* Yes No Do you have at least 5 bowel movements in a 7-day period?* Yes No Are you currently experiencing significant rectal bleeding, diarrhea, abdominal pain, anemia, or severe and unexpected weight loss?* Yes No Have you had an episode of diverticulitis in the past 6 weeks?* Yes No Tell us a little more about your general health and medications.Do you use supplemental oxygen, such as an oxygen tank or oxygen concentrator?* Yes No Have you ever had difficulties with any of the following:*Have you ever had difficulties with any of the following:* Anesthesia (beyond nausea and vomiting) A known difficult airway or intubation Surgery or radiation on your throat, larynx, or voice box Yes No Do you have any of the following medical conditions or devices?*Do you have any of the following medical conditions or devices?* Pacemaker or defibrillator Heart stents, heart bypass surgery, or heart valve surgery History of heart failure, heart attack, or stroke (within the last 3 months) Seizure (within the last 3 months) Emphysema or other lung conditions Abnormal heart rhythm (other than atrial fibrillation) Aortic stenosis Yes No Can you independently transfer to and from an exam bed?* Yes No Are there any upcoming cardiology or pulmonary tests, such as a stress test, echocardiogram, or pulmonary function tests, that you have scheduled?* Yes No Are you on any blood thinning medications other than aspirin? (Examples include Coumadin® (warfarin), Lovenox, XARELTO® (rivaroxaban), AriXtra® (Fondaparinux), Plavix® (clopidogrel), Effient® (prasugrel), Eliquis® (apixaban), BrilintaTM (ticagrelor), etc.).*Are you on any blood thinning medications other than aspirin? (Examples include Coumadin® (warfarin), Lovenox, XARELTO® (rivaroxaban), AriXtra® (Fondaparinux), Plavix® (clopidogrel), Effient® (prasugrel), Eliquis® (apixaban), BrilintaTM (ticagrelor), etc.). * Yes No Are you currently taking any of the following GLP-1 medications?*Are you currently taking any of the following GLP-1 medications? * Weekly Injectables Bydureon BCise® (Exenatide) Ozempic® (Semaglutide) Byetta® (Exenatide) Rybelsus® (Semaglutide) Wegovy® (Semaglutide) Victoza® (Liraglutide) Mounjaro® (Tirzepatide) Saxenda® (Liraglutide) Trulicity® (Dulaglutide) Zepbound® (Tirzepatide) Daily Medications Byetta® (Exenatide) Rybelsus® (Semaglutide) Victoza® (Liraglutide) Saxenda® (Liraglutide) Phentermine Medications (Atti-pex) Adipex® Fastin® Phentercot® Pro-Fast® Qsymia® If you are taking any of the listed GLP-1 medications, you must stop taking them seven (7) days before your procedure. Yes No Are you currently taking any of the following diabetic medications (SGLT2)?*Are you currently taking any of the following diabetic medications (SGLT2)? * Weekly Injectables Farxiga® (Dapagliflozin) Invokana® (Canagliflozin) Jardiance® (Empagliflozin) Steglujan® (Ertugliflozin/Sitagliptin) Synjardy® (Empagliflozin/Metformin) If you are taking any of the listed SGLT2 medications, you must stop taking them three (3) days before your procedure. Yes No Almost finished! Give us just a few more details.Tell us about yourself.First Name* Last Name* Birthday*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age*Address* ZIP Code Phone*Email* Primary Care Physician InformationFirst Name Last Name PhoneEmail Do you have a preferred physician, or would you like the first available appointment?Preferred PracticeFirst AvailableAssociates in Digestive HealthAtlanta Gastroenterology AssociatesDeKalb Gastroenterology AssociatesDigestive Care PhysiciansEast Atlanta Gastroenterology AssociatesGastroenterology Associates of AthensGastroenterology Associates of Southwest FloridaGastroenterology Group of NaplesThe Center for Digestive & Liver HealthPreferred ProviderFirst AvailableBrent W. Acker, MDBasil S. Al-Awabdy, MDGirish Anand, MDGeorge C. Aragon, MDSrinivasa (Srini) R. Ayinala, MDAnthony Balistreri, MDJames C. Barlow, MDMahmoud B. Barrie, MDErin S. Barth, MDMichael Bays, DOChristopher A. Brown, MDEdward C. (Chris) Cameron, MDJoel Camilo, MDSteven L. Carpenter, MD, MACPDaniel N. Castresana, MDHitesh R. Chokshi, MDMichelle P. Clermont, MDSusan G. Coe, MDBradley Creel, MDEric D. Davis, MDJae Dong, MDCharles W. Duckworth, MDMark D. Edge, MDRobert M. Eisenband, MDBrian Feiock, MDChristopher Fernandez, MDDavid Finkelman, MD, MBA, FACG, AGAFTemitope Foster, MDCharles A. Fox, MD, MBA, CPEBrian Frank, MDMichael H. Frist, MDMichael F. Fry, MDLuis M. Galvez, MDZachary W. Garner, MDJay H. Garten, MDSagar S. Garud, MDMihajlo Gjeorgjievski, MDNicole M. Gordon, MDKelly C. Grow, MDAmanda Guentner, MDNitin K. Gupta, MDMustafa Haroon, MDTommie Haywood III, MDTal B. Hazan, MDEric D. High, MD, FACGDale C. Holly, MD, MHCDSH. Sooki Hon, MD, PhDJawad A. Ilyas, MDKayin Jeffers, MDMirza A. Kajani, MDBruce T. Kalmin, MDParesh P. Kamat, MDNandha Kanagarajan, MDJonathan Kandiah, MDYasmin K. Karim, MDHetal A. Karsan, MDLeah G. Katta, MDAmmara Khalid, MDJae H. Kim, MDRamesh Koka, MDKavita R. Kongara, MDMichael S. LeVine, MDBarry Levitt, MDAnna V. Longacre, MDLori J. Lucas, MDRalph C. Lyons, MDEnrique J. Martínez, MDAja S. McCutchen, MDA. Steven McIntosh, MD, FACGBrett Mendel, MDJai Eun (Jenny) Min, MDRuth D. Montalvo, MDÁngel B. Morales-Santiago, MDSteven J. Morris, MDDaniel K. Mullady, MDMubashar Munir, MDMark E. Murphy, MD, FACP, AGAFC. Gregory Nesmith Jr., MDLong B. Nguyen, DOMark R. Nyce, MDKamil Obideen, MDNgozi I. Okoro, MDNeal K. Osborn, MDSanjay R. Parikh, MDNitin J. Parikh, MDKeval A. Patel, MDNeal C. Patel, MDNeal R. Patel, MDBhavin M. Patel, MDJoyce C. Peji, MDJulian Perez-Barrios, MDErik B. Person, MDDonald M. Pham, MDGirish Poré, MDDavid N. Quinn, MDDavid Rabin, MDDimple Raina, MDBrian Rajca, MDSrinivas Raju, MDStephen J. Rashbaum, MDAnupama Ravi, MDMarc D. Rosenberg, MDMadeline R. Russell, MDJessica Russell, MSN, AGACNP-BCEdward Rydzak, MD, AGAFPatricia A. Sánchez, MDNadia S. Sanford, MDNick Sharma, MDBradley D. Shepherd, MDAparna P. Shreenath, MDAndrew J. Simpson, MDNina Singh, MDRanvir Singh, MDDavid N. Socoloff, DOMarc B. Sonenshine, MDGouri Sreepati, MDMark A. Stern, MDJohn Suh, MD, MPHJyotsna Talapaneni, MDJon V. Trankina, MDBradley Trope, MDRyan C. Wanamaker, MDAdam J. Weinberg, MDKaren Weiss-Schorr, MDPaul Weissblatt, MDDouglas C. Wolf, MDBMI CalculationEnter your heightFeet*Please enter a number less than or equal to 8.Inches*Please enter a number less than or equal to 12.Enter your weight (pounds)*Please enter a number less than or equal to 1500.Your BMI*StatusHiddenEligibleHiddenIneligibleQuestionnaire ConsentThe answers provided will be used to determine your plan of care and will become part of your permanent medical record. If you are completing the questionnaire on behalf of the patient, verify the accuracy of each answer before submitting.Depending on the results of your questionnaire, you may be eligible to schedule your colonoscopy and bypass the pre-procedure visit. However, we realize some patients are more comfortable meeting the physician prior to the procedure.Please select one of the options below: If eligible, I would like to proceed with scheduling the colonoscopy directly. Regardless of my eligibility, I would like to schedule an office visit with my physician to discuss the procedure before the colonoscopy. Congratulations! Based on the responses you submitted in our Direct Access Colonoscopy medical questionnaire, you are eligible for our Direct Access Program. In the coming days, a team member will contact you to discuss your questionnaire, answer remaining questions, and schedule your procedure. We are committed to providing high-quality care and appreciate the significance of your treatment decision. The United Digestive Team Thank you for completing our online Direct Access Colonoscopy medical questionnaire. Unfortunately, your responses indicate that you do not currently meet the criteria for the Direct Access Program and will require an office visit. A dedicated team member will contact you within 2 business days to discuss your situation, answer questions, and get you scheduled with one of our providers. If you would like to contact us directly, please call 404-888-7590. We appreciate your understanding and look forward to assisting you further. The United Digestive Team Δ