What is your age? <45 45-50 50-55 55-60 60-65 65-70 70-75 >75 Has anyone in your family (parents, siblings, children, grandparents etc.) ever been diagnosed with colon cancer? Yes No Do you have a personal history of colon polyps or cancer? Yes No Are you having any of the following symptoms? Blood in stool Change in bowel habits Unexplained weight loss Anemia or low blood counts Other (add in comments) Other symptoms * Thank you!