Are you at risk for colorectal cancer?

Early cancer detection is crucial. Since colorectal cancers typically begin as polyps, undergoing screenings for colorectal cancer is highly recommended by the American Cancer Society for early detection and measuring.

The colorectal cancer screening tool relies on established risk factors recognized by the medical community for colorectal cancer. We aim for this tool to facilitate a conversation about colorectal cancer risk and screening options with your doctor. However, it’s important to note that this tool does not constitute medical advice. The results from the tool will be provided shortly after completion by a member of the Capital Digestive Care team.

Colorectal Cancer Screening Assessment

Colorectal Cancer Screening Tool

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First Name(Required)

Last Name(Required)

Email(Required)

Phone Number(Required)

What area do you prefer to receive care?(Required)

What Maryland city do you live nearest to?(Required)

Search what Capital Digestive Care office is nearest to you.

What Virginia Tidewater city do you live nearest to?(Required)

Search what Capital Digestive Care office is nearest to you.

Maryland & DC Area Offices

Are you between the age 45-70?(Required)

Yes

What is your birthdate?(Required)

MM slash DD slash YYYY

Are you currently pregnant or trying to become pregnant?(Required)

Yes

Have you ever been treated for Diabetes, Hepatitis, Kidney or Liver Diseases or bleeding disorder?(Required)

Yes

Have you been treated or currently taking medications for Hypertension (high blood pressure)?(Required)

Yes

Do you have a history of neurological conditions-seizures, multiple sclerosis or Parkinson’s?(Required)

Yes

Have you had any gastroenterology or weight loss surgeries in the past six months?(Required)

Yes

Have you taken medications for weight loss within the past six months or do you plan to start a weight loss plan that includes taking medications for weight loss?(Required)

Yes

Have you received treatment for any respiratory conditions, such as asthma, chest pain, home oxygen use, chronic obstructive pulmonary disease, lung disease, sarcoidosis, shortness of breath, or sleep apnea?(Required)

Yes

Select any respiratory conditions that you have been treated for(Required)

Asthma

Chest pain

Home oxygen

Chronic obstructive pulmonary disease

Lung disease

Sarcoidosis

Shortness of breath

Sleep apnea

Are you currently experiencing any gastroenterological conditions, such as abdominal pain, constipation, diarrhea, a history of IBD like Crohn's or ulcerative colitis, rectal bleeding, or unexplained weight loss?(Required)

Yes

Select the gastroenterology conditions that you are currently experiencing(Required)

Abdominal pain

Constipation or diarrhea

History of IBD Crohn’s or Ulcerative Colitis

Rectal bleeding

Unexplained weight loss

Have you been treated for any cardiac conditions?(Required)

Yes

Have you been treated for any of these cardiac conditions?(Required)

Atrial fibriliation

Cardiac ablation

Cardiac stent

Defibrillator or pacemaker

Heart attack

Heart surgery

Stroke/TIA

Congestive heart failure

Cardiomyopathy

Chest pain/angina

Do you take any medications, such as blood thinners (excluding 81 mg of Aspirin), narcotic pain medications, or weight loss medications (GLP-1)?(Required)

Yes

Select the type of medications you take.(Required)

Blood thinners excluding 81 mg of Aspirin

Narcotic pain medications

Weight loss medications (GLP-1)

Other

Select other if your medications is not listed.

What medications do you take?(Required)

Is your BMI under 40?(Required)

Yes

Not sure

Look up your BMI with the CDC BMI Calculator.

Have you had a colonoscopy procedure?(Required)

Yes

When did you have your last colonoscopy?(Required)

MM slash DD slash YYYY

If you don’t recall the exact date, use the first date of the month. i.e. 05/01/1992

Do you have a personal history of any type of cancer?(Required)

Yes

Is this a cancer diagnosis active and currently being treated?(Required)

Yes

Virginia Tidewater Area Offices

What is your age?

What is your birthdate?(Required)

MM slash DD slash YYYY

Have you had past issues with heartburn or acid reflex?(Required)

Yes

Have you had any gastroenterology or weight loss surgeries in the past six months?(Required)

Yes

Have you taken medications for weight loss within the past six months or do you plan to start a weight loss plan that includes taking medications for weight loss?(Required)

Yes

Have you had any of the following issues?(Required)

None

Seizures

Multiple sclerosis

Parkinson’s disease

Yes

Select the gastroenterology conditions that you are currently experiencing(Required)

Abdominal pain

Constipation or diarrhea

Inflammatory bowel disease

Crohn’s

Ulcerative colitis

Rectal bleeding

Unexplained weight loss

Yes

Select any respiratory conditions that you have been treated for.(Required)

Asthma that is not controlled

Chest pain

Lung disease

Chronic obstructive pulmonary disease

Emphysema

History of positive tuberculosis

Home oxygen

Sarcoidosis

Shortness of breath

Sleep apnea with BMI over 35

Sleep apnea using bi-pap

Have you been treated for the following?(Required)

None

Diabetes

Kidney problems (renal failure, transplant, dialysis)

Liver disease or transplant

Advanced liver disease complicated by ascites

Bleeding disorder

Do you take any medications, such as blood thinners, hypertension medications, high blood pressure medications, narcotic pain medications, or weight loss medications?(Required)

Yes

Select the type of medications you take.(Required)

Blood thinners (excluding 81 mg aspirin)

Hypertension medications

High blood pressure medications

Narcotic pain medications

Weight loss medications

Other

Select other if your medication is not listed.

What medications do you take?(Required)

Have you undergone treatment for any cardiac conditions, such as atrial fibrillation, cardiac ablation, cardiac stent placement, defibrillator or pacemaker implantation, heart attack, heart surgery, stroke/TIA, congestive heart failure, cardiomyopathy, or chest pain?(Required)

Yes

Select any cardiac conditions you have undergone treatment for.(Required)

Atrial fibriliation

Cardiac ablation

Cardiac stent

Defibrillator or pacemaker

Heart attack

Heart surgery

Stroke/TIA

Congestive heart failure

Cardiomyopathy

Chest pain/angina

When was the date of your last cardiac episode?(Required)

MM slash DD slash YYYY

Is your BMI under 40?(Required)

Yes

Not sure

Look up your BMI with the CDC BMI Calculator

Do you have a personal history of cancer?(Required)

Yes

Is this a cancer diagnosis active and currently being treated?(Required)

Yes

Have you had a colonoscopy procedure?(Required)

Yes

What was the date of your last colonoscopy?(Required)

MM slash DD slash YYYY

What were the results of your last colonoscopy?(Required)

Comments

This field is for validation purposes and should be left unchanged.

Are you at risk for colorectal cancer?

Colorectal Cancer Screening Tool

Maryland & DC Area Offices

Virginia Tidewater Area Offices

Related Resources

Colon Cancer Prevention

Colon Cancer Screening for Patients Age 45 and Older

Colonoscopy

Colon Polyps and Colon Cancer