Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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: ______________