Bowel Check Questionnaire

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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?
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