How old are you?What is your sex? Male Female Do you get at least 30 minutes of moderate exercise on most days? Yes No Are you a vegetarian? Yes No The average American gets approximately 40 percent of calories from fat. Would you estimate that your diet consists of LESS THAN 30 percent of calories from fat? Yes No Do you drink more than 14 alcoholic beverages per week? One alcoholic beverage is considered to be one 12-ounce bottle or can of beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of 80-proof distilled spirits. Yes No What is your smoking history? I smoke. I don't smoke now, but I have smoked in the past. I have never smoked. Do you have a parent, sibling, or child who has been diagnosed with colorectal cancer? Yes No Please check the box if you have ever been diagnosed with: Colorectal adenomatous polyps Crohn's disease Ulcerative colitis Familial adenomatous polyposis Hereditary nonpolyposis colon cancer (HNPCC), also known as Lynch syndrome Gardner Syndrome None of the above Have you had Crohn's disease for more than 10 years? Yes No Have you had ulcerative colitis disease for more than 10 years? Yes No Email* Phone*Zip Code* ZIP / Postal Code This assessment is not intended to replace the evaluation of a healthcare professional.
