Prostate Exam and Colonoscopy Procedure Questionnaire Form
Please complete this form to provide your intake information for your upcoming prostate exam and colonoscopy procedure.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What is the main reason for your upcoming procedure?
*
Routine screening
Family history of cancer
Symptoms (e.g., bleeding, pain, changes in bowel habits)
Follow-up from previous findings
Other
Do you have any current symptoms?
*
Rectal bleeding
Abdominal pain
Changes in bowel habits
Unexplained weight loss
None of the above
Other
Do you have any allergies?
*
No known allergies
Yes (please specify below)
If yes, please list your allergies
Please list any medications you are currently taking
Have you had a prostate exam or colonoscopy before?
*
Yes, both
Yes, prostate exam only
Yes, colonoscopy only
No
Emergency contact name and phone number
*
Submit
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