COLORECTAL CANCER - CRC - CONSENT FORM
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If you are younger than 40 years old but consider yourself high risk or
40 years old and average risk,
please print out the below consent form, fill it out, and bring it with you to your
appointment.
THANK YOU! |
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:
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____ FOBT*, DRE^, annually starting at 40 with
colonoscopy, only if positive |
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____ FOBT*, DRE^ annually starting at 40 with sigmoidoscopy every 5 yrs starting at 50
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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 what you did before you had the procedure done. NOTHING. |
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____ Double Contrast Barium Enema –[Not preferred if other screens are available] |
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____ Virtual Colonoscopy every 5 to 10 yrs starting at 50, sooner if high risk. |
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____ Colonoscopy every 10 yrs starting at 50, sooner if high risk. |
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____ DNA Testing every 3 to 5 years starting at 50, sooner if high risk. |
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____ Colonoscopy every 10 yrs with DNA Testing every 5 yrs spaced between the colonoscopies starting at 50, sooner if high risk. |
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____ Other:_____________________________________________________ |
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____ 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
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