Direct access colonoscopy

To schedule a direct endoscopy for your patient, please complete the following:

Yes	No
		Active heart disease or heart attack within past 12 months
		Unstable COPD (emphysema)
		Stroke within past 6 months
		Unstable diabetes
		AICD or pacemaker placement within past 6 months
		Organ transplant
		Active cancer diagnosis or treatment
		Age >75 years
		Coumadin, Plavix or Ticlid use
		Weight >300 pounds
		Hospitalization within past 6 months for congestive heart failure, asthma or COPD (emphysema)
		Psychosis or cognitive impairment