First name

Second name

Phone number

Email

Gender
Male Female

Date of Birth

Height in inches

Weight in Pounds

Primary care Doctor

Pharmacy name

Insurance carrier

Member Id

Group Id

Name of insured

Insured date of birth

Relationship

Insurance customer service phone

Have you had Colonoscopy in the past?
Yes No

Do you have a family history of Colon Cancer or Colon Polyps? Colon Cancer Colon Polyps None

Are you allergic to any medications?
Yes No

Do you take any medication(s) that thin your blood like the ones listed below?
None Aspirin Plavix (Clopidogrel) Effient Brilinta Coumadin (Warfarin) Xarelto Pradaxa Eliquis

Please list all medications below including any over-the-counter medications, natural medications, vitamins and supplements

Are you currently experiencing or recently experienced any symptoms such as weight loss, abdominal (belly) pain, blood in the stool, black stool, heartburn requiring regular use of medicines, constipation, diarrhea or any change in your bowel habits?
Yes No

Have you ever been told that you are anemic? (have a low blood count)
Yes No

Do you have a pacemaker or implanted defibrillator device?
Yes No

Have you ever been diagnosed with an Inflammatory Bowel Disease such as Crohn's Disease or Ulcerative Colitis?
Yes No

Have you had any of the following medical conditions?
Stent Placement Heart Attack (MI), Congestive heart Failure (CHF) or Arrhythmia (Irregular Heartbeat) Seizures or Fainting Spells Stroke Sleep Apnea or other chronic respiratory illness such as Asthma, COPD or Emphysema Diabetes Thyroid Disorders Obesity Kidney Disease with or with out Dialysis Organ Transplant Cancers or leukemia

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