Please select one of the following prefixes* must provide value
Dr.
Mrs.
Ms.
First Name* must provide value
Last Name* must provide value
Street Address* must provide value
City* must provide value
State* must provide value
Zip code* must provide value
Phone number (daytime phone number)* must provide value
Include Area Code
Secondary phone number (work, mobile, etc.)
E-mail * must provide value
Preferred method of contact:* must provide value
Primary phone
Secondary phone
Email
Date of birth* must provide value
Today M-D-Y
Do you CURRENTLY smoke, use nicotine, or use chewing tobacco?* must provide value
Yes
No
Please explain* must provide value
Do you work between the hours of 11 PM and 6 AM (night shift or swing shift) or have an unusual sleeping pattern?* must provide value
Yes
No
Please explain* must provide value
Have you used any street drugs (i.e. marijuana, cocaine, meth, etc.) in the last year?* must provide value
Yes
No
Please explain* must provide value
How many alcoholic drinks (12 ounces of beer, 5 ounces of wine, or 1.5 ounces of hard liquor) do you normally have in a week? Please enter 0 if you do not drink.* must provide value
Are you post-menopausal (defined here as NOT having a menstrual period in the last 12 months)? * must provide value
Yes
No
Please list all medications AND vitamins or supplements you are currently taking, including* must provide value
Do you have lupus, multiple sclerosis, rheumatoid arthritis, or other immune disorder?* must provide value
Yes
No
If yes, please give dates and details. * must provide value
Do you have any orthopedic or arthritis problems?* must provide value
Yes
No
If yes, please give dates and details. * must provide value
Do you have COPD?* must provide value
Yes
No
If yes, please give dates and details. * must provide value
Do you have vascular disease or have you had a stroke?* must provide value
Yes
No
If yes, please give dates and details. * must provide value
Do you have an implantable defibrillator, pace maker, congestive heart failure, or life threating heart condition?* must provide value
Yes
No
If yes, please give dates and details. * must provide value
Do you have any other cardiovascular problems?* must provide value
Yes
No
If yes, please give dates and details. * must provide value
Do you have diabetes, hyperglycemia, or pre-diabetes?* must provide value
Yes
No
If yes, please give dates and details. * must provide value
Have you ever had seizures, epilepsy, or convulsions? * must provide value
Yes
No
If yes, please give dates and details. * must provide value
Do you have kidney or liver problems?* must provide value
Yes
No
If yes, please give dates and details. * must provide value
Do you have thyroid or other hormone problems? * must provide value
Yes
No
If yes, please give dates and details. * must provide value
Do you have a history of cancer or tumor other than breast cancer?* must provide value
Yes
No
If yes, please give dates and details. * must provide value
Have you had a breast cancer recurrance?* must provide value
Yes
No
Please explain* must provide value
Do you have any of the following gut-related disorders?* must provide value
Irritable Bowel Syndrome
Ulcerative Colitis
Inflammatory Bowel Disease
Crohn's Disease
Other
None of the above
Please list the other gut-related disorder(s) you have been diagnosed with* must provide value
Has a doctor ever told you that you have Parkinson's disease?* must provide value
Yes
No
Has a doctor ever told you that you are HIV positive or that you have AIDS?* must provide value
Yes
No
If you have been hospitalized or had surgery since your previous CRC visit, please list the reason(s) why, and also the dates of hospitalization. If you have not been hospitalized or had surgery in the past year, please write "None"* must provide value
If you have any other major health problems, please describe them.
Please list any allergies you have (medications, seasonal, foods, animals, etc.)
Have you taken antibiotics within the past two months?* must provide value
Yes No
Why were you taking them and when did you stop?* must provide value
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