*Please provide your full legal name as it appears on
your driver's license, state identification card, or government issued identification card.
* Required Information
Patient Medical History
Mark all conditions that you have had. If you have had none in a category, mark None.
* Gastrointestinal Conditions
* Non-Gastrointestinal Conditions
* Please mark if a relative has had any of the following.
* Have any of your blood relatives had Colorectal Cancer?
* Have any of your blood relatives had Colon Polyps?
Currently Active Symptoms, Tests & Other Conditions
Select all that apply. If you have no symptoms in a category, select NONE.
* Head, Ears, Eyes, Nose & Throat
Have you had any of these procedures?
* Please mark all surgeries you have had including the date.
Personal and Social History
* Do you consume alcohol?
Average number of drinks per week now?
Average number of drinks per week in past?
* How would you describe your cigarette smoking?
How many packs per day do you smoke?
How many packs per day did you smoke?
How many years have you smoked?
How many years did you smoke?
* Do you use other tobacco products?
* How many caffeinated beverages do you consume per day?
* IV drug use or other recreational drug use?
* Have you engaged in high risk behavior for sexually transmitted diseases (anal sex, unprotected sex,
* Have you ever had a blood transfusion?
* Have you had any recent foreign travel?
* Do you have any body piercings?
* Do you have any tattoos?
* Please select any of these allergies you have.
If you have any additional medication allergies, please bring in list with reaction to your
If you are taking medications, please bring an accurate list at time of your appointment.