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Personal Colon Cancer Screening Record

Track Your Colorectal Cancer Prevention Journey

Gastroenterology

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Template Content

Last updated: Mar 24, 2025

Patient Information

Name: _________________________ Date of Birth: _________________ Medical Record #: ______________

Screening History

Colonoscopy Records

Date Provider Findings Next Due Date

Other Screening Tests

Stool-Based Tests

  • FIT (Fecal Immunochemical Test)

    • Date: _________ Result: _________
    • Date: _________ Result: _________

  • Cologuard®

    • Date: _________ Result: _________
    • Date: _________ Result: _________

Risk Factors (Check all that apply)

□ Family history of colorectal cancer □ Personal history of polyps □ Inflammatory bowel disease □ Lynch syndrome □ Familial adenomatous polyposis

Recommended Screening Schedule

  • Average risk: Begin at age 45
  • High risk: Begin at age 40 or 10 years before youngest affected relative
  • Screening interval: □ 1 year □ 3 years □ 5 years □ 10 years

Notes

Important Contact Information

Gastroenterologist: _____________ Phone: ________________________ Clinic: ________________________

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