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St. Francis-Emory Healthcare Colorectal Screening Questionnaire
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Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Phone Number
*
Your answer
Email Address
*
Your answer
Have you had recent unexplained weight loss?
*
Yes
No
Have your bowel habits changed? (Diarrhea, Constipation, Incomplete emptying of bowels)
*
Yes
No
Are you experiencing rectal bleeding?
*
Yes
No
Do you have a family history of colon cancer?
*
Yes
No
Do you have abdominal pain?
*
Yes
No
Do you have a personal history of colon polyps?
*
Yes
No
Have you had a colonoscopy?
Yes
No
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When was your last Colonoscopy?
MM
/
DD
/
YYYY
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