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The Terre Haute Chamber of Commerce would like to welcome guest blogger, Dr. Sharma of Digestive Health Associates. Dr. Sharma has created an employee and employer health questionnaire. 

digestive health

  Colonoscopy Cancer Screening Questionnaire

 

  • Do you currently smoke tobacco? YES/NO (circle)

If yes, approximately how many packs per day? _____

If yes, approximately for how many year? _____

  • Do you currently drink alcohol? YES/NO (circle)

If yes, approximately how many drinks per week? ______

  • Are you between the ages of 50-85? YES/NO (circle)

If not, how old are you? ______

  • Do you currently have any of the following? Select ALL that applies
  • Abdominal pain, bloating, or cramping
  • Change in bowel habits
  • Blood in stool/Black stool
  • Rectal bleeding
  • Diarrhea
  • Constipation
  • Unintentional weight loss
  • Fatigue
  • Change in stool size and shape
  • In the past, have you ever had a colonoscopy? YES/NO (circle)

If yes, approximate date of colonoscopy? __________

If yes, what was the result? Select from the following

  • Normal
  • Polyp(s)
  • Other: _____________
  • Any personal family history of colon cancer? YES/NO (circle). If yes, please specify from the following (i.e. Mother, 45 yrs. old)
  • Relationship __________________ Age of diagnosis _______
  • Relationship __________________ Age of diagnosis _______
  • Relationship __________________ Age of diagnosis _______
  • Relationship __________________ Age of diagnosis _______
  • Any personal family history of colon polyps? YES/NO (circle)
  • Any personal family history of the following? Select ALL that applies
  • Ulcerative colitis
  • Crohn’s disease
  • Celiac disease (Sprue)
  • Cirrhosis of the liver
  • Breast cancer
  • Kidney cancer
  • Ovarian cancer
  • Uterus cancer
  • Stomach cancer
  • Pancreatic cancer
  • Have you ever been diagnosed with cancer? YES/NO (circle)

If yes, what primary organ was involved? ____________________

If yes, date of first diagnosis?_______________________

  • Have you ever been diagnosed as having Lynch Syndrome or HNPCC Syndrome? YES/NO/UNSURE (circle)
  • Are you on any blood thinner (s)? YES/NO (circle). If yes, please specify from the following blood thinners:
  • Plavix
  • Coumadin (Warfarin)
  • Lovenox
  • Aggrenox
  • Pletal
  • Other: ________________