Wellness - Cancer Risk and Prevention
Risk Evaluation Form

Developed for the Cancer Center’s Colon Cancer Early Detection and Prevention Program

What’s Your Risk?  We know that the risk for colon cancer is increased by certain dietary, environmental, and/or hereditary factors.  To help us appreciate how various factors may contribute to your risk for colon cancer, please take a few minutes to answer the questions on this self-survey.  All of your information will remain confidential.

Today's Date *Name(First) *(Last) Company name (if applicable) *Address Line 1: Address Line 2: *City: *State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY Other *Zip: Phone Number Date of Birth Gender Male Female 1. Please indicate your race or ethnic background: White (non-Hispanic) Hispanic African-American Asian Native American Other, specify 2. Are you 50 years or older? YesNo 3. Have you or any members of your family been diagnosed with colon, ovarian and/or uterine cancer? No Yes - If yes, who? (please check all that apply) Type of Cancer Self Age at Diagnosis Type of Cancer Mother Age at Diagnosis Type of Cancer Father Age at Diagnosis Type of Cancer Sibling Age at Diagnosis Other 4. Have you or any members of your family been diagnosed with benign polyps (small, non-cancerous growths in the colon)? No Yes - If yes, who? (please check all that apply) SelfMotherFatherSiblingOther 5. Do you have inflammatory bowel disease (specifically ulcerative colitis or Crohn’s disease)?              YesNo   Check here if greater than 10 years 6. Have you ever been screened for colon cancer? Please check all that apply. Yes, Fecal occult Blood Test (FOBT) on (date) Yes, Sigmoidoscopy on (date) Yes, Colonoscopy on (date) No: If you’ve never been screened (or are overdue), please check all reasons that apply Do not have health insurance   No symptoms      No family history of colon cancer     My doctor never mentioned it Have limited health insurance Didn't feel it was necessary Hesitant about colon cancer screening methods Do not have a doctor Other, specify 7. How many servings of vegetables do you eat each day? Note: one serving equals a cup of raw leafy greens or 1/2 cup of other vegetables, cooked or raw. 1-23-5More than 5 8. How many times a week do you eat red meat? None1-34 or more 9. How would you classify your diet? Low fatModerate fatHigh fat 10. What is your weight range? UnderweightAverageOverweight 11. How often do you engage in physical activity (i.e. walking, dancing, etc.)? NeverOnce or twice a weekAt least 3 times a week 12. How often do you drink alcohol? Never1-3 times a week4-7 times a week7 or more times a week 13. Do you smoke? YesNo 14. Do you take a multivitamin/mineral supplement every day? YesNo Congratulations!  Taking the time to learn about your risk for colon cancer is an important step towards preventing it. Once this survey is reviewed and your risk for colon cancer determined, we will provide additional information and recommendations specific to you. Please check here if you do not want to be added to our Colon Cancer Program  mailing list: