●Age
① >40yrs ②<40yrs
●Chronic diarrhea?
①Yes ②No
●chronic constipation?
①Yes ②No
●Have you ever had dark stool or stool with mucus?
①Yes ②No
●Do you have chronic appendicitis or even removed your appendix?
①Yes ②No
●Do you have chronic gall bladder inflammation or even removed your gallballder?
①Yes ②No
●Have you suffered from major stress or agony in the past 20 years?
①Yes ②No
●Have you ever been diagnosed with cancer
①Yes ②No ③If yes, please describe it further: what type of cancer? Diagnosed in xxxx/xx/xx Diagnosed at which hospital?
●Have you ever been found to have colon polyp
①Yes ②No
●Is there anyone among your 1st degree relatives (parents, siblings, children) diagnosed with colon cancer?
①Yes ②No ③Unknown
●Have you ever had a positive fecal occult blood test?
①Yes ②No
●Is your diet rich in fats, proteins and/or low in fiber?
①Yes ②No
●Are you overweight or lack of exercise?
①Yes ②No