Doctors & Services

Endoscopy Centre


Colorectal Cancer Risk* Compulsory fields

Your Name*

Date of Birth*

Telephone No.*

Residential District

Height (m)*

If 5 feet 3 inches = 1.6m

Weight (kg)*

If 140 lbs = 63kg


Please complete the below questionnaire

1Gender

2Do you have any of the below colorectal cancer symptoms?

3Do you have any first degree relative(s) (parents, siblings or children) diagnosed with colorectal polyp, advanced adenoma or cancer?*

Age

4Have you done colorectal cancer screening with any of the below screening tool?

5Have you been diagnosed with the below colorectal disease?

Please choose

6Have you been diagnosed with the below disease or encounter situation below?

7Have you been diagenosed with the below disease?

If "tick" others, please write down the disease

8Have you ever had abdominal operation?

Type of Operation

9Do you warfarin or anti?

Please choose

10Do you smoke?