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Name *

DOB *

Email *

Address *

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What is your age ? *

In the past 3 months, have you had any changes in your bowel habits, including any of the following? * Rectal bleeding or blood in your stoolFrequent changes in your bowel habits, including diarrhea or constipationPencil-thin stoolsFeeling that you have to empty your bowel but nothing passesUnexplained weight lossNew or worsening belly painNone of the above

Have you ever had any of the following screening test for colorectal cancer? *

Do you have a history of any of the following? * Diverticulosis flare up in the past monthInflammatory bowel disease (IBD), including chronic ulcerative colitis or Crohn's diseaseRectal or colon ulcers in the past monthMinor bowel or rectal surgery (such as having hemorrhoids removed, surgery to treat an anal fissure, etc.) within the past 3 monthsMajor bowel or rectal surgery (such as removal of part or all of your large intestine, colectomy, etc.)None of the above

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