Robert S. Cutler, D.O. - Colon Screening

Port St. Lucie Office
Directions: Take l-95 or the Turnpike to Port St. Lucie Boulevard Exit East. Travel east of the turnpike approximately 1 ½ Miles. Office is on south side in the Delo Plaza.

West Palm Beach Office
I-95 to Forest Hill Boulevard travel West over turnpike to SR7/441. Turn right (North), office is on Left (West).

TURNPIKE to Southern Boulevard (SR80) exit# 97. Travel West 2.5 miles to SR7/441. Turn left (South) and travel approximately 2 miles. Office is on the right.

TURNPIKE to Lake Worth Road, exit# 94. Travel west 2.0 miles to SR7/441. Turn right (north) and travel approximately 2.5 miles. Office is on left.

The office is across from the Wellington Green Mall behind Wellington Medical Center. The entrance is on the West side of SR7/441. The office is located in the South Pink Building, "Wellington Medical Arts Pavilion." Take the elevator to the Fourth Floor and exit left (1st door).

	First		Last
Name:

	Street
Address: (Optional)
	City	State	Zip


E-Mail:

	Home		Work
Phone Number(s):
	Pager		Fax

Do you currently suffer from, or have you had any recurring symptoms of:
Rectal Discomfort	Yes	No
Rectal Protrusion, or Bulging	Yes	No
Difficulty in Holding Bowel Movements	Yes	No
Rectal Seepage	Yes	No
Lower Abdominal Aches, Cramping, or Pain	Yes	No
Constipation, Diarrhea, Frequency	Yes	No
Changes in Your Bowel Habits	Yes	No
Growths Around the Anus	Yes	No

Discharge of Pus or Development of Cysts (Lumps) from the Anus, Surrounding Tissues, or Tailbone	Yes	No
Rectal Itching	Yes	No

Have you ever had rectal bleeding or bright red or pink discharge on tissue after wiping?	Yes	No

Polyps (growths) or cancer (bowel, rectal or lower intestinal)?	Yes	No
A blood relative with a history of colon or rectal polyps?	Yes	No
A blood relative with a history of colorectal cancer?	Yes	No
Ulcerative colitis or Crohn's disease?	Yes	No

Have you had any of the following examinations:
Rectal (finger) exam?	Yes	No
Hemoccult stool exam?	Yes	No
Sigmoidoscopy (a look into your lower colon)?	Yes	No
Colonoscopy (a look around your entire colon)?	Yes	No
Men only: PSA (prostate specific antigen), a blood test?	Yes	No

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Robert S. Cutler, D.O.
Board-Certified Proctologist
E-Mail Us: robcut1@aol.com

10115 West Forest Hill Boulevard
Suite 401
Wellington, FL 33414
(561) 842-5050

514 Port St. Lucie Boulevard
Port St. Lucie, FL 34984
(772) 871-6222

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