Record your answers to the following questions:



Do you have a family history of colon or rectal cancer?
(Immediate family only: mother, father, sibling)


Do you have a personal history of colon or rectal cancer? YES NO
a. If yes, when was it discovered?


Do you have a history of colitis? YES NO


Do you have a personal history of colon or rectal polyps? YES NO


Have you ever had:
a. Breast cancer YES NO
b. Ovarian cancer YES NO
c. Endometrial (uterine) cancer YES NO
d. None of the above YES NO


Have you ever had a colon examination? YES NO
If yes, please circle what type:
a. Digital exam by a physician YES NO
b. Proctoscopy YES NO
c. Flexible sigmoidoscopy YES NO
d. Colonoscopy YES NO
e. Barium enema YES NO
If yes, please indicate date of your last exam:


Have you noticed blood in:
a. Your stool YES NO
b. In the toilet water YES NO
c. On the toilet paper following a bowel movement YES NO


Have you noticed a change in your bowel habits recently? YES NO

If you have answered yes to any of the above questions you should see your doctor and begin colon cancer screening


This material is intended for informational purposes only and is not a substitute for the medical advice of your doctor or any other health care professional. Always consult with your physician if you are in any way concerned about your health.

© 2003 - 2005 SLPM Self-care Ltd.

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