CUHK Medical Centre Limited

Your Name*

Date of Birth*

Telephone No.*

Residential District

Height (m)*

Weight (kg)*

Please complete the below questionnaire

Gender

Male

Female

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

Yes

If yes, please specify the first degree relative(s) (parents, siblings or children), he/she is diagnosed with which disease (colorectal polyp, advanced adenoma or cancer) and the age when discovering this disease

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

Colonoscopy

Capsule endoscopy

Fecal immunochemical test

Barium enema

Flexible sigmoidoscopy

None of the above

Have you been diagnosed with the below colorectal disease?

Polyp

Adenoma

Cancer

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

Diabetes

Fatty liver

First degree relatives diagnosed with colorectal cancer

None of the above

Have you been diagenosed with the below disease?

Hypertension

Myocardial infarction/Heart disease

Chronic obstructive pulmonary disease

Stroke

GERD

Obesity

None of the above

Others, please specify below

If "tick" others, please write down the disease

Have you ever had abdominal operation?

Yes, please specify below

Type of Operation

Do you warfarin or anti?

Warfarin

Plavix

Aspirin, usage amount (Per pill)

Do you smoke?

Yes for now / used to

I would like to receive gastrointestinal-related information from CUHK Medical Center

I am interested in participating health check or research organized by CUHK Medical Centre

I agree to provide my above information to CUHK Medical Centre for the use in research

I agree to be contacted by centre staff for preliminary consultation

Colorectal Cancer Risk