Colorectal Cancer Risk Assessment

This confidential assessment can help give you a better idea of your risk of developing colorectal cancer. While it can’t replace an evaluation by a medical professional, it’s a good starting point to better understand your colorectal health and get the best possible care.

First Name*

Last Name*

Email*

Phone*

Date of Birth*

ZIP Code*

Let's Keep In Touch

Yes, I want AdventHealth to send me information about its various service via phone, email or direct mail.

If you are having a medical emergency, please call 911.

25%

Progress 25%

Check your risk level for Colorectal Cancer

*This tool does not replace an evaluation by a medical professional.

What is your age?*

Have you had a close relative (parent, brother, sister or child) with colon cancer?*

Do you have a history of polyps in your colon?*

Do you have a history of inflammatory bowel disease?*

Are you overweight?*

50%

Progress 50%

Check your risk level for Colorectal Cancer

*This tool does not replace an evaluation by a medical professional.

Do you smoke or have you ever smoked?*

Are you physically active?*

Do you eat a diet high in red meats, processed meats and other fats?*

Do you eat a diet low in fiber, grains, vegetables and fruits?*

Do you have Type 2 Diabetes?*

75%

Progress 75%

Check your risk level for Colorectal Cancer

*This tool does not replace an evaluation by a medical professional.

Do you drink alcohol?*

Have you ever been diagnosed with cancer of the breast, ovary or uterus?*

Are you African-American?*

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Progress 100%

HRA__c

HRA - HRA__c - Case

Total Score

Request Reason

Area_of_Interest__c

Area of Interest - Area_of_Interest__c - Case

Type

Type - Case

Status

Status - Case

ServiceLine__c

Service Line - ServiceLine__c - Case

Request_Manager__c

Request Manager Request_Manager__c Case

Subject

Subject - Subject - Case

Campus_Submitted__c

Campus Submitted - Campus_Submitted__c - Case

Case Origin

Case Origin - Origin - Case

Line__c

Line - Line__c - Case

ReferralPath__c

ReferralPath - ReferralPath__c - Case

ReferralValue__c

ReferralValue - ReferralValue__c - Case

Referral_Source__c

Referral Source - Referral_Source__c - Campaign

Campaign__c

Campaign - Campaign__c - Case

CampaignChannel__c

Campaign Member - Status

Status - Status - CampaignMember

LeadSource

Lead Source - LeadSource - Contact

Email_Opt_In_Description__c

Email Opt In Description - Email_Opt_In_Description__c - Contact

Campaign Name

This hidden field has been added by Attribution to CRM Plugin to store Campaign Name in this Form's submission table

Campaign Source

This hidden field has been added by Attribution to CRM Plugin to store Campaign Source in this Form's submission table

Campaign Content

This hidden field has been added by Attribution to CRM Plugin to store Campaign Content in this Form's submission table

Campaign Medium

This hidden field has been added by Attribution to CRM Plugin to store Campaign Medium in this Form's submission table

Campaign Term

This hidden field has been added by Attribution to CRM Plugin to store Campaign Term in this Form's submission table

Requested_Physician_Name__c

Preferred Physician - Requested_Physician_Name__c - Case

NPI__c

Guide_Choice__c

Guide Choice - Guide_Choice__c - Case

GCLID (Google Click Identifier)

This hidden field has been added by Attribution to CRM Plugin to store GCLID (Google Click Identifier) in this Form's submission table