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Get Checked!
Congratulations on deciding to get screened for Colon Cancer! Please complete these simple questions to order your At-Home screening test from Harvard Street Neighborhood Health Center. Once your screening test is complete, you will be notified to receive a $25 gift card!
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* Indicates required question
First Name
Non
*
Your answer
Last Name
Siyati
*
Your answer
Street Address
Non ri kote w rete
*
Your answer
City / State
Vil / Eta
*
Your answer
Zip Code
Kòd postal
*
Your answer
Email
*
Your answer
Phone Number
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Have you been screened for Colon Cancer before?
*
Yes
No
If you've been screened for Colon Cancer before,
approximately when was your last screening?
Your answer
If you've been screened for Colon Cancer,
what kind of screening did you most recently have (at-home test, colonoscopy, sigmoidoscopy?)
At Home Non-Invasive Test (i.e. FIT or Cologuard)
Colonoscopy
Sigmoidoscopy
Not Sure
Other:
Do you have a family history of Colon Cancer?
*
Yes
No
Unknown
Do you have Irritable Bowel Syndrome, Crohn's Disease or Ulcerative Colitis?
*
Yes
No
Not Sure
Do you have any symptoms that concern you? (such as rectal bleeding, a change in bowel habits, abdominal discomfort, unusual loss of weight?)
*
yes
no
not sure
Thank you! Your screening will be on its way to you soon! Anything else you think we should know?
Your answer
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