Colorectal Risk Assessment

Please be aware this program is usually covered by insurance, however, you may be responsible for a copay. If your insurance requires a referral, you will need to obtain one from your doctor.

To determine if this program is appropriate for you please answer a few brief questions.

Please complete the assessment below to determine if this program is appropriate for you. If you are eligible, a referral specialist will contact you within two business days to gather more detailed information.

Contact Information

Are you the patient? *

Have you ever been seen at Roswell Park Cancer Institute?


Has this individual ever been seen at Roswell Park Cancer Institute?

Would you like to join our mailing list?

Patient's Contact Information
Eligibility

Do youDoes the patient have a personal or family history of any of the following?

More than 20 colon polyps in total, of any kind?

More than 10 colon polyps (precancerous or adenomatous)?
*This should not include hyperplastic or serrated polyps.

Rare types of colon polyps (hamartomatous or juvenile)?

Colon polyps (precancerous or adenomatous) diagnosis under age 40?
*This should not include hyperplastic or serrated polyps.

Early onset colon cancer (cancer diagnosis under age 50)?

Do youDoes the patient have a personal or family history of any hereditary colon cancer susceptibility syndrome such as:

Familial Adenomatous Polyposis (FAP) or attenuated form (AFAP)?

MUTYH-Associated Polyposis (MAP)?

Lynch syndrome or HNPCC (Hereditary Nonpolyosis Colorectal Cancer syndrome)?

Peutz-Jegher syndrome?

Juvenile Polyposis?

Li-Fraumeni syndrome?

Cowden syndrome?