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First Name:
Last Name:
Email:
Phone:
What is your current rating?
N/A
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Please list down all CURRENT Disability/ies and rating/s for each. (Write N/A if you do not have any current disability rating. Eg PTSD 70%, Sleep Apnea 50%)
Are you taking any prescription medications? If so, please list which ones with dose and frequency if known in the box provided below.
Yes
No
Are you taking any over the counter medications? If so, please list which ones with dose and frequency if known in the box provided below.
Yes
No
Have you ever been diagnosed with the condition you are being prescreened for? If yes, please explain in the box provided below.
Yes
No
In the last 3 months, how often did you have discomfort or pain anywhere in your rectum/anus?
All of the time
Most of the time
Some of the time
Never
Have you experienced this discomfort or pain for 6 months or longer?
Yes
No
For women only: Did this discomfort / pain occur only during menstruation and not at other times?
Yes
No
How often did this discomfort / pain improve or stop after you had a bowel movement?
All of the time
Most of the time
Some of the time
Never
How often did this discomfort / pain worsen during or after you had a bowel movement?
All of the time
Most of the time
Some of the time
Never
After this discomfort / pain started, did you experience more frequent bowel movements?
All of the time
Most of the time
Some of the time
Never
After this discomfort / pain started, did you have less frequent bowel movements?
All of the time
Most of the time
Some of the time
Never
After this discomfort / pain started, were your bowel movements looser?
All of the time
Most of the time
Some of the time
Never
After this discomfort / pain started, how often did you have harder stools?
All of the time
Most of the time
Some of the time
Never
Over the last 3 months, how often did you produce hard or lumpy stools?
All of the time
Most of the time
Some of the time
Never
Over the last 3 months, how often did you produce loose or watery stools?
All of the time
Most of the time
Some of the time
Never
Over the last 3 months, how often did you experience difficulty having a bowel movement (straining, feeling that you have not finished)?
All of the time
Most of the time
Some of the time
Never
Over the last 3 months, how often did you feel you had to rush to the bathroom as soon as you noticed the urge to have a bowel movement?
All of the time
Most of the time
Some of the time
Never
Over the last 3 months, how often did you feel bloated?
All of the time
Most of the time
Some of the time
Never
Over the last 3 months, how often did you feel that your abdomen was actually visibly distended?
All of the time
Most of the time
Some of the time
Never
Are any of the following diseases present in your family? - Colon cancer - Celiac disease - Inflammatory bowel disease (Ulcerative colitis, Crohn's disease)
Yes
No
Have you experienced unintentional weight loss over the past 3 months?
Yes
No
Over the past 3 months did you see blood in the toilet with your stool?
All of the time
Most of the time
Some of the time
Never
Over the past 3 months if you saw blood in the toilet with your stool? How much blood was there?
N/A - None
Only on toilet paper
Streaks on stool
Drops in the water
Teaspoon
Tablespoon
More than a Tbsp
Did your symptoms wake you up at night over the past 3 months?
All of the time
Most of the time
Some of the time
Never
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