Cancer Please reply to question on next step to see if you qualify Cancer Email Name Phone Name of reference Do you have a colonoscopy consult, colonoscopy prep, or colonoscopy procedure scheduled? Yes No What is the date of your appointment? Skip this question, if you do not have an appointment at this time. Are you between the ages of 45-85 (within the next 90 days)? Yes No Have you had a colonoscopy in the last nine years (since 2012)? Yes No I do not know Have you had a stool (poop) test (specifically a fecal immunochemical test (FIT)) in the last 6 months? Yes No I do not know Have you been treated for cancer (except for non-melanoma skin cancer) in the past five years? Yes No I do not know Do you have inflammatory bowel disease (IBD)—either ulcerative colitis (UC) or Crohn’s disease (CD)? Yes No I do not know Have two or more members of your immediate family ( (Father, Mother, Child, Siblings or half- Siblings) had colorectal cancer (also known as bowel cancer, colon cancer, or rectal cancer)? Yes No I do not know Have you been diagnosed with colorectal cancer or had a polyp or growth known as an adenoma in your colon or rectum? Yes, colorectal cancer Yes, Adenoma Polyp Yes, other type of Polyp No I do not know Time is Up! Time's up
