Frankford Hospitals - Center for Gynecology & Women’s Health at Frankford Hospitals

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Center for Gynecology & Women’s Health at Frankford Hospitals

Colorectal Cancer Risk Assessment

Women can answer the following questions to get a sense of their
likelihood of having or developing cancer colon (large intestine) or rectum.

Do you eat a diet that is low in fiber?	Yes	No
Do you eat a diet that is high in fat?	Yes	No
Are you over age 50?	Yes	No
Have you ever been diagnosed with colorectal polyps?	Yes	No
Do you have an immediate family member (parent, child, or sibling) who has had colorectal polyps or colorectal cancer?	Yes	No
Have you ever been diagnosed with IBD (inflammatory bowel disease in the form of ulcerative colitis or Crohn’s disease)?	Yes	No
Have you ever had breast, uterine, or ovarian cancer?	Yes	No
On average, do you consume the equivalent of more than one alcoholic beverage per day?	Yes	No
Are you overweight?	Yes	No
Is your lifestyle inactive?	Yes	No
Have you ever smoked?	Yes	No
Have you had screening for colorectal cancer, according to your age recommendations?	Yes	No
Are you African American or of Eastern-European Jewish descent?	Yes	No
Have you noticed blood in your stool recently?	Yes	No
Have you noticed a disruption of your bowel habits that lasts for more than a few days?	Yes	No
Have you had pain, bloating, or cramping in your abdomen?	Yes	No
Have you had weight loss, or tiredness and weakness that you cannot explain?	Yes	No
Have you ever been diagnosed with a colorectal cancer that has previously been removed?	Yes	No

The more often you answered “Yes” to the above questions, the greater your risk for developing or having colorectal cancer. If you answered “Yes” to questions above, consider discussing colorectal cancer with one of our Women’s Center healthcare providers.

Print this page and bring it with you, filled out, to your appointment.

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