Demographic and General Information

1.	Gender:	Male □	Female □
2.	Year of birth:	____________________________________________
3.	I currently have an ostomy	Yes □	No □
	Previously had an ostomy—now reversed	□
	Ostomy: An operation that makes it possible for stool to leave the body through an opening made in the abdomen. This surgery is sometimes medically required when a part of the intestines is removed. Colostomy and ileostomy are types of ostomies. Your Treatment History for Colorectal Cancer
4.	Select one that applies to you:		Tickhere
		I have had surgery only	□
		I have had surgery and chemotherapy	□
		I have had surgery and radiation therapy	□
		I have had surgery with both chemotherapy and radiation therapy	□
		I have had chemotherapy and radiation therapy	□
		I have had chemotherapy only	□
		I have had radiation therapy only	□
		I have had no treatments	□
		I am currently having radiation	□
		I am currently having chemotherapy	□
		I am currently having both radiation therapy and chemotherapy	□
5.	I completed all of the above treatments OR made the decision not to have any treatments on this date:
		Month:	Year: