Questionnaire Before Your Test


Name: DOB:                          Age:
Address:

Marital Status:   Married  Single  Common-law  Widowed  Divorced Gender:   M   F
Health Card No: Occupation:
Smoking:   Y   N Alcohol: Y      ________/week       N

Please tell us about your health:

  Y N Please Specify:
Do you have FREQUENT bowel function problems?      
Has your bowel function changed?      
Have you ever passed blood?      
Do you have serious tummy pain?      
Recent weight loss?     If YES, then was the weight loss voluntary?   YES   NO
       

Family History of Colorectal Cancer and/or Polyps (Circle answer): YES (Fill Table below) NO

  Member #1 Member #2 Member #3 Member #4
Colon/Bowel Cancer        
Colonic Polyps        

Please list your MEDICAL CONDITIONS and past SURGERIES:

     
     
     
     

Please list your MEDICATIONS (Name, Dosage, Frequency):

   
   
   
   
   
   
   


Drug Allergies?

EMERGENCY CONTACT:

PHONE:


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