Join Research Programme

Name *

Date of birth *

Contact *

Residential district

Email

Height(m) *

If 5 feet 3 inches = 1.6m

Weight(kg) *

If 140 lbs = 63kg

1. Gender

Male
Female

2. Do you have any of the below colorectal cancer symptoms?

Per rectal bleeding
Maelena
Mucous
Persistent narrowing of stool
Unexplained diarrhea or constipation
Tenesmus
No appetite
Anemia
Weight loss (10lbs within 6 months)
None of the above

3. Do you have any first degree relative(s) (parents, siblings or children) diagnosed with colorectal polyp, advanced adenoma or cancer? *

Yes
None

{
"relatives":["Parents","Siblings","Children"],
"disease":["Polyp","Advanced adenoma","Colorectal cancer"],
"age":"Age"
}

Should you have another first degree relatives diagnosed with colorectal polyp, advanced adenoma or colorectal cancer, please press “+” button, if not, please go to next question

4. Have you done colorectal cancer screening with any of the below screening tool?

Colonoscopy
Capsule endoscopy
Fecal immunochemical test
Barium enema
Flexible sigmoidoscopy
None of the above

5. Have you been diagnosed with the below colorectal disease?

No
Yes

If yes, please choose

Polyp
Adenoma
Cancer

6. Have you been diagnosed with the below disease or encounter situation below?

Diabetes
Fatty liver
First degree relatives diagnosed with colorectal cancer
None of the above

7. Have you been diagenosed with the below disease

Hypertension
Myocardial infarction/Heart disease
Chronic obstructive pulmonary disease
Stroke
GERD
Obesity
Others
None of the above

If "tick" others, please write down the disease

8. Have you ever had abdominal operation?

No
Yes

If yes, please write down the type of operation

9. Do you warfarin or anti

No
Yes

If yes, please "tick"

Warfarin
Plavix
Aspirin

Please fill in the Aspirin usage amount(Per pills)

10. Do you smoke?

Yes for now /used to
No

I would like to receive gastrointestinal-related information from CUHK

I am interested in participating health check or research organized by CUHK

I agree to provide my above information to CUHK and S.H. Ho Centre for Digestive Health for the use in research

I agree to be contacted by centre staff for preliminary consultation

General query

Getting Info

Please tell us about you

Please complete the below questionnaire