First Name *
Last Name *
Email Address *
-- Select Country --UNITED STATES
Phone Number *
Date of Birth *
Are you currently under a medical doctor’s care?
If yes, please explain
Are you pregnant?
List all known allergies
List all medications (including over the counter)
What do you hope to achieve from this appointment?
Please check whether you have or had any of the following:
-- Please select --Severe Cardiac DiseaseUlcerative colitisRecent colon surgeryAneurysmCrohn’s diseaseRenal insufficiencySevere AnemiaCirrhosisFissures / FistulasGI hemorrhage/perforation1st trimester of pregnancyChemo/Radiation TXSevere HemmorhoidsAdvanced PregnancyCancerSevere DiverticulitisAbdominal HerniaAids
If answered yes to any please explain
Have you had recent surgeries? If yes, please explain
Are you currently taking the following medications: Coumadin, Heparin, Plavix (blood thinners)?
I have honestly answered all above questions and am not intentionally withholding information about my health.
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