NMCSD Colon Cancer Screening and Colon Polyp Surveillance Questionnaire

Request for a Colonoscopy


Thank you for taking time out of your busy schedule to fill out this Patient Assessment.

Our partnership in your care will help ensure the highest quality medical care for you.


 *** IMPORTANT ***

If you do not answer the questions completely or correctly your procedure may be cancelled.

We use this information to make sure that you can undergo the procedure safely.


Please click NEXT to begin your assessment.

There are 36 questions in this survey.