Personalized Colon Cancer Screening Management Plan

Patient Information

• Name: ________________
• Date of Birth: ________________
• Medical Record Number: ________________
• Primary Care Provider: ________________

Risk Assessment

Personal Risk Factors (to be completed by healthcare provider)

• Family history of colorectal cancer
• Personal history of polyps
• Inflammatory bowel disease
• Genetic syndromes (Lynch, FAP)
• Other risk factors: ________________

Risk Category

• Average risk
• Increased risk
• High risk

Recommended Screening Schedule

Primary Screening Method

• Recommended test: ________________
• Frequency: ________________
• Next scheduled screening: ________________

Alternative Options (if applicable)

1. Colonoscopy every 10 years
2. FIT test annually
3. Cologuard every 3 years
4. CT colonography every 5 years

Follow-up Plan

Previous Screening Results

• Date of last screening: ________________
• Method used: ________________
• Findings: ________________

Action Items

• Schedule next screening
• Complete preparation instructions
• Review dietary restrictions
• Arrange transportation

Important Reminders

Preparation Guidelines

• Follow prescribed bowel preparation exactly
• Adjust medications as directed
• Maintain clear liquid diet when instructed
• Arrange for post-procedure care

Warning Signs to Report

• Unexplained weight loss
• Blood in stool
• Change in bowel habits
• Persistent abdominal pain

Contact Information

Medical Team

• Gastroenterologist: ________________
• Office Phone: ________________
• After Hours: ________________

Emergency Contacts

• Emergency Contact Name: ________________
• Relationship: ________________
• Phone: ________________

This plan should be reviewed and updated annually or as needed based on screening results and changes in health status.