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ColoWell America | Proctology and Aesthetics Care

Pre-Screening Questionnaire for Fast Track Colonoscopy

Please fill out the following form to help us understand your medical condition.

 

Fast Track Colonoscopy

Pre-Screening Questionnaire for Fast Track Colonoscopy.

Name(Required)
Did you doctor refer you for a colonoscopy due to Blood in your Stool?(Required)
For the past 30 days, have you had any Constipation, Diarrhea, or Abdominal Pain?(Required)
For the past 6 months, have you had any Rectal Bleeding or Anemia?(Required)
Have you had any Seizures, Fainting, or Dizziness from an Unknown Cause?(Required)
Are you on any Blood Thinner Medications?(Required)
Have you had any Weight Loss Procedures in the Last 5 Years?(Required)
Are you in between the ages of 50-75, or if African American age 45-75?(Required)

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(813) 278-6430

Contact Via Fax

(855) 832-3509

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Address: 2313 W Violet St., Ste A Tampa, FL 33603

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