1. Do you eat animal fat?
   Yes    No
2. Are you older than 50 years?
   Yes    No
3. Have you ever had a colon polyp?
   Yes    No
4. Do you have inflammatory bowel disease?
   Yes    No
5. Has a relative of yours had colon cancer?
   Yes    No
6. Is that relative a mother, father, sister, brother, son or daughter?
   Yes    No
7. How many other relatives have had colon cancer?
   None   One    Two    More
8. Do you have hemorrhoids?
   Yes    No
9. Have you had an ureterosigmoidostomy?
   Yes    No
10. Do you use tobacco?
    Yes    No

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