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. 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

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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