Barnes-Jewish Hospital - Colon and Rectal Cancer Prevention Program Risk Assessment

The Alvin J. Siteman Cancer Center Colon and Rectal Cancer Prevention Program Risk Assessment

Please answer the following questions:

1.	Age over 50?	Yes No
2.	Have you ever had polyps or cancer of the colon or rectum?	Yes No
3.	Do you have any close family members (parents, children, brothers, sisters) who have had polyps or cancer of the colon or rectum?	Yes No
4.	Have you ever been told that you have Crohn's colitis or ulcerative colitis?	Yes No
5.	Have you had any recent bloody or black stools?	Yes No
6.	Have you noticed any change in your bowel movements (constipation and/or diarrhea)?	Yes No