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