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

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