Schedule your Colonoscopy
Thank you for taking the time to fill out the below questions so we may schedule your Screening Colonoscopy. Someone from our office will contact you to schedule. 
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Name *
Phone Number *
What is your birthdate? *
MM
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DD
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YYYY
Email *
Are you between the age 45-75? *
Are you currently pregnant or trying to become pregnant? *
Have you ever been treated for Diabetes, Hepatitis, Kidney or Liver Diseases or bleeding disorder? *
Have you been treated or currently taking medications for Hypertension (high blood pressure)? *
Do you have history of neurological conditions- seizure, multiple sclerosis or Parkinson's? *
Have you had any gastroenterology or weight loss surgeries in the past six months? *
Have you received treatment for any respiratory/ lung conditions, such as asthma, chest pain, home oxygen use, chronic obstructive pulmonary disease, lung disease, sarcoidosis, shortness of breath, or sleep apnea? *
Are you currently experiencing any gastroenterological conditions, such as abdominal pain, constipation, diarrhea, a history of IBD like Crohn's or ulcerative colitis, rectal bleeding, or unexplained weight loss? *
Have you been treated for any cardiac/ heart conditions? (other than high blood pressure) *
Do you take any medications such as blood thinners (excluding 81mg Aspirin), narcotic pain medications, or weight loss medications (GLP-1)? *
Is your BMI under 40?
Look up your BMI with the CDC BMI Calculator:
 *
Have you ever had a colonoscopy procedure? *
Do you have a personal history of any type of Cancer? *
Do you have a first degree relative with Colon Cancer? If Yes, who? *
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