Bowel Check Questionnaire

About Endoscopy

About bowel cancer

Other gastro intestinal disease

Patient Information
& Education

Health Funds Info

High fibre diet

If you feel you may be at risk and wish to be tested, please fill out the simple questionnaire below and we will contact your doctor with our recommendations.

Have you or a close family member had bowel cancer?	Yes	No
Have you or a close family member ever had Bowel Polyps?	Yes	No
Any Blood with your Bowel Motion?	Yes	No
Persistent Change in your Bowel Habits?	Yes	No
Have you had Cancer of Breast?	Yes	No
Have you had Cancer of Uterus?	Yes	No
Ulcerative Colitis or Crohn's Disease?	Yes	No

NAME:
ADDRESS:
SUBURB:
PHONE (BUSINESS):
PHONE (PRIVATE):
Email:
AGE:
LOCAL DOCTOR:

Are you at risk?

Has a family member had bowel cancer or polyps?

Any blood with your bowel motion?

Persistent change in bowel habits?

© Peninsula Endoscopy Centre 2011 267 Cranbourne Road Frankston 3199 Vic. Aust. Ph. (03) 9781 5888 Fax. (03) 9783 2319

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