Download Please indicate if you have any of the following symptoms

Please indicate if you have any of the following symptoms by checking ‘YES’ or ‘NO’:
YES
NO
Bothersome joint pains
Sexual problems (getting and keeping erections, completing intercourse, etc.)
Change in size or firmness of stools
Blood in stool or black/tarry bowel action
Change in size or color of a skin mole
Difficulty with sleeping
Often feeling sad, hopeless, or depressed
Often having little interest or pleasure in doing things
Difficulty with urine stream (difficulty starting, weak stream, dribbling)
Getting up frequently at night to urinate
Chest pains, shortness of breath
Problems doing routine tasks at home or stumbling and/or falling
Periods of weakness, numbness or difficulty in talking
Heartburn or stomach problems
Please indicate if you have a mother, father, sister or brother with the following by checking ‘YES’ or ‘NO’:
Heart attack, stroke, or blockage of the arteries before age 55
Cancer of the colon or intestine
Please indicate if you have any of the following by checking ‘YES’ or ‘NO’:
YES
NO
Do you have high blood pressure
Do you have heart disease
Have you had cancer
Do you have high cholesterol
Alcohol: do you drink more than 10 drinks a week or more than 2 drinks a day
Do you smoke tobacco
Do you use smokeless tobacco
Please use this space to add any additional information regarding any question checked ‘YES’ above or any
other information you consider important:
COLON CANCER SCREENING
If colon cancer is detected at an early stage through screening, the cure rate is very high. We strongly recommend
colon cancer screening for all men over age 50. Screening should begin at age 40 if there has been a case of colon
cancer in your mother, father, sister or brother.
There are multiple acceptable methods to screen for colon cancer (described below). Please indicate your decision
by selecting of one the following choices by placing an “X” in the box to the left of one of the following choices:
Stool card test – this is done at home by an easy method of collecting a specimen on a card and mailing it in
for analysis. If this is the method you choose, it should be repeated once a year. We have these stool card kits
and can give to you today to take home and complete. If you are getting colonoscopy/sigmoidoscopy (see
below), we recommend you complete this stool card test on years in between the scopes.
Barium enema – this is an x-ray involving filling your colon with barium through an enema and taking a
series of x-rays. This method is repeated every 5 years if normal. We can give you orders to have this exam at
a local x-ray department.
Endoscope exams (includes colonoscopy and sigmoidoscopy) – this involves a specialist inserting a scope
into your colon and looking for abnormalities. This is the most thorough form of screening but is does carry a
small risk of damage to the colon. Depending on which type of endoscope exam you and the specialist decide
upon, this screening is repeated every 5 to 10 years if normal and stool card testing should occur on the years
in between the scopes. We can give you a referral to a specialist that performs this test.
I decline/refuse any form of colon cancer screening – if this is your choice, we will respect your decision,
but must emphasize that this could delay the diagnosis should you ever develop colon cancer. This could
result in serious complications, including death.
PROSTATE CANCER SCREENING
If prostate cancer is detected at an early stage through screening, the cure rate is very high. We recommend
prostate cancer screening for all men over age 50. Screening should begin at age 40 if there has been a case of
prostate cancer in your father or brother or if you are an African-American.
You should be aware that some authorities oppose prostate screening. This opposition is based on the fact that
current screening and diagnostic methods cannot always accurately predict which prostate cancers are highly
malignant and which are very slow growing. Opponents to screening feel this leads to many men receiving
unnecessary treatment which can produce serious complications such as loss of bladder control and impotence. We
feel that you should have access to testing that can detect cancer at the earliest stage possible. If you are diagnosed
with prostate cancer, you may always refuse any treatment for cancer if you feel the potential complications of
treatment outweigh the potential benefit.
The primary test for prostate cancer screening is a PSA (Prostate Specific Antigen) blood test. Please indicate your
decision by selecting of one the following choices by placing an “X” in the box to the left of one of the following
choices:
I authorize you to schedule a PSA test to screen for prostate cancer.
I decline/refuse prostate cancer screening – if this is your choice, we will respect your decision, but must
emphasize that this could delay the diagnosis should you ever develop prostate cancer. This could result in
serious complications, including death.
Signature: ______________________________ Today’s date: ____________
DOB: ______________