I have read the Power Point Presentation on Colorectal Cancer. I feel I am:
____ Average Risk, recommended to begin screening at 40
____ High Risk, recommended to begin screening before 40 [All below ages would be  adjusted earlier according to level of high risk]

I have chosen the below procedures to screen for CRC:
* ____ FOBT*, DRE^, annually starting at 40 with colonoscopy, only if positive
* ____ FOBT*, DRE^ annually starting at 40 with sigmoidoscopy every 5 yrs starting at 50 [ This only works for men. Women's spontaneous CRC usually begins on the right side of the colon and a sigmoidoscopy does not reach that far. Thus if the procedure returns negative, you essentially know nothing more than what you did before you had the procedure done. ]
* ____ Double Contrast Barium Enema –[Not preferred if other screens are available]
* ____ Virtual Colonoscopy every 5 to 10 yrs starting at 50, sooner if high risk.
* ____ Colonoscopy every 10 yrs starting at 50, sooner if high risk.
* ____ DNA Testing every 3 to 5 years starting at 50, sooner if high risk.
* ____ Colonoscopy every 10 yrs with DNA Testing every 5 yrs spaced between the colonoscopies starting at 50, sooner if high risk
* ____ Other:_____________________________________________________
* ____ I prefer not to screen for colorectal cancer even though that decision may prove detrimental to my longevity. I understand that CRC is preventable but prefer to forgo these evaluations presently.

 Signed:__________________________________ Date:_________________

FOBT* = Fecal Occult Blood Testing
DRE^ = Digital Rectal Exam