Colon Cancer Screening Questionnaire
Please complete this questionnaire to help assess your risk for colon cancer. Your responses are confidential and will assist in determining if further screening is recommended.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Other
Do you have a family history of colon cancer?
*
Yes
No
Not Sure
Which family member(s) had colon cancer?
Parent
Sibling
Grandparent
Other
Have you ever been diagnosed with any of the following?
*
Colon polyps
Inflammatory bowel disease (IBD)
Ulcerative colitis
Crohn's disease
None of the above
Are you currently experiencing any of the following symptoms?
*
Blood in stool
Unexplained weight loss
Persistent abdominal pain
Change in bowel habits
None of the above
Lifestyle Risk Factors
*
Rows
Yes
No
Do you smoke?
1
2
Do you drink alcohol regularly?
3
4
Do you eat a diet low in fiber?
5
6
Do you exercise less than 3 times per week?
7
8
Have you had a colon cancer screening test before?
*
Yes
No
If yes, what type of screening have you had?
Colonoscopy
Fecal occult blood test (FOBT)
Flexible sigmoidoscopy
Other
When was your most recent colon cancer screening?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
On a scale of 1 to 5, how concerned are you about your risk for colon cancer?
*
Not at all concerned
1
2
3
4
Very concerned
5
1 is Not at all concerned, 5 is Very concerned
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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