
Risk Assessments
Colorectal Questionnaire
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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) |
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 |
| 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 |
Know your medical history and see your doctor regularly.
Although not all risk factors can be controlled, your lifestyle choices can affect colon health.
If you answered "yes" to 3 or more questions, you may be at risk for colorectal disease, and it is strongly recommended that you review the above colon-health risk assessment with your doctor. If you need an internist or a gastrointestinal (GI) specialist, please call the Columbia University Medical Center Physician Referrals line at 1.800.227.2762.
If you answered "yes" to 3 or more questions, you may be at risk for colorectal disease, and it is strongly recommended that you review the above colon-health risk assessment with your doctor. If you need an internist or a gastrointestinal (GI) specialist, please call the Columbia University Medical Center Physician Referrals line at 1.800.227.2762.


