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Educational Resources
Risk Assessments


Colorectal Questionnaire

Submit the following questionnaire to us and it will be reviewed and evaluated. We will contact you and you will be notified as to risk according to American Medical Association recommendations.

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Select the appropriate answer:
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. ProctoscopyYES 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
9.Would you like to receive information regarding screening examinations for colorectal disease? YES NO
10. Would you like to make an appointment with one of our CUMC colorectal specialists? YES NO

Name
Address
Email Address (e.g. barry@aol.com)
Date of Birth (e.g. 05/13/1950)
Phone (e.g. 645-012-0000)



Click here to download the questionnaire and mail to:

Columbia University Medical Center
External Affairs, Mail Code 94—Department of Surgery
622 West 168th Street
New York, NY 100032

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