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PLEASE CIRCLE SIGNIFICANT SYMPTOMS THAT YOU ARE HAVING:

  difficulty swallowing?    If yes, is it with solids , liquids or both.        

  pain on swallowing?      If yes, is it in the throat or in the chest:

 severe or persistent heartburn ?

 frequent indigestion ?

 episodes of nausea or vomiting?

 fill up very easily?

significant change in your bowel habits?

constipation?   If yes, how frequently do you have a bowel movement?

diarrhea?      If yes, is it soft, mushy, loose, watery, mucousy.

symptomatic hemorrhoids?       Anal itching?   Anal discomfort or pain?

rectal bleeding?      On the toilet paper?   Into the bowl?

blood  on  or mixed in with the stool?

black tarry stools?

Have you been told you have a positive stool test for blood?

Have you been told that you have iron deficiency?

Have you been told that you have anemia?

Do you have a personal history of a rectal or colon polyp?

Do you have a personal history of a rectal or colon cancer?

Have you ever had a colonoscopy examination ?

Have you ever had a flexible sigmoidoscopy examination?

Have you ever had an upper endoscopy examination?

Jaundice,   unusual itching, change in the color of urine (dark like coca-cola) or stool (light like clay color).

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