Colon Cancer Colorectal Questionnaire

Record your answers to the following questions:
1.	Do you have a family history of colon or rectal cancer? (Immediate family only: mother, father, sibling)	YES	NO
2.	Do you have a personal history of colon or rectal cancer?	YES	NO
	a. If yes, when was it discovered?
3.	Do you have a history of colitis?	YES	NO
4.	Do you have a personal history of colon or rectal polyps?	YES	NO
5.	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
6.	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:
7.	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
8.	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

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