Information & Downloads

Form 3-2
Form 3-1

Patient Questionnaire

Do you suffer from Constipation?

Do you suffer from Diarrhea?

Do you have to strain or push hard when having a bowel movement?

Does any tissue ever come out of your rectum (prolapse) during a bowel movement?

Do you often feel like you’re “still not done” after a bowel movement?

On average, do you drink the equivalent of 6-8 glasses of water per day?

Are you taking any fiber supplements?

Time spent on toilet during average bowel movement in minutes?

Symptoms (in Rectal Area)

Are you allergic to latex?

Are you pregnant?

Are you taking any blood thinners (Coumadin, Plavix, Pradaxa, Xarelto, Eliquis, etc.)?

Have you ever been diagnosed with Crohn’s disease, proctitis, cirrhosis or anal/rectal cancer?

Are you taking immunosuppressant medication or undergoing radiation treatments?

Have you ever had a colonoscopy?

Patient Consent

Please Check Box

Fax: (714) 596-0551

18800 Delaware Street, Suite 850
Huntington Beach, CA 92648