Colon Cancer FIT Test Screening Questionnaire

Thank you for your interest in our free fecal occult (hidden) blood screening event. This test detects fecal blood at a very low level which can be an early warning sign for colon cancer or other gastrointestinal bleeding. A positive test would be an indication for further evaluation.

To determine if you are eligible for the FIT (Fecal Immunochemical Test) screening option, complete this pre-screening questionnaire. Please allow 7 days for processing of the questionnaire.

If your medical history meets the requirements, you will be contacted by phone and/or email to receive a free FIT test mailed to your home. Instructions on next steps will be included. Tests are available while supplies last. The processing for the test will be complimentary. If your history does not meet the requirements, you will be notified by email.

 

EEHEALTH Colon Cancer FIT Test Screening Questionnaire

Contact Information
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Medical History
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Have you ever been diagnosed with colorectal cancer or pre-cancerous polyps?

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Has your mother, father, brother(s), sister(s) or child ever been diagnosed with colorectal cancer?

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Have you ever been diagnosed with inflammatory bowel disease (Ulcerative Colitis or Crohn’s disease)?

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Please select which, if any, of the following symptoms you are having:





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Please select which, if any, of the following screenings you have had in the past 2 years:





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Please select which, if any, of the following screenings you have had in the past 10 years:





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