FIELD	DETAIL	NOTES/ALLOWED VALUES
ANTHROPOMETRIC DATA
Weight		Numeric [Kg]
Height		Numeric [cm]
BMI		Numeric [calculated automatically]
BSA		Numeric [calculated automatically]
Age		Numeric
age class		<50 >50
PERSONAL RATINGS
Family History for colorectal cancer (detail visible only if “Yes” and repeatable)	Yes/No
	Kind of relationship	Mother Father Brothers Sisters Maternal grandparents Paternal grandparents Uncles/aunts Other
	Notes
Family History for cancer (detail visible only if “Yes” and repeatable)	Yes/No
	Kind of relationship	Mother Father Brothers Sisters Maternal grandparents Paternal grandparents Uncles/aunts Other
	Notes
Personal background for other malignancies	Yes/No
	Notes
Hereditary genetic alterations (detail visible only if “Yes” and repeatable)	Yes/No
	Type	Polyposis associated with MutYH or MAP mutation Colon attenuated polyposis (AFAP) Classic colon polyposis (FAP) Lynch syndrome
	Notes
Predisposing pathologies (detail visible only if “Yes” and repeatable)	Yes/No
	Type	Diabetes hyper cholesterolemia Hypertension Hypertriglyceridemia Crohn’s disease Rectal ulcerative colitis Metabolic syndrome
	Notes
Risk factors (detail visible only if “Yes” and repeatable)	Smoker	Yes/No
	SMOKER DETAILS (visible only if indicated Smoker = yes)
		Smoker (visible only if indicated Smoker)	Smoker Current Former smoker
		Cigarette smoking	Yes/No
		Number of cigarettes per day [if current smoker]	weak (<15) strong (≥15)
		Years of smoke	Numeric
		Number of years of cessation [if ex-smoker]	≤15 >15
		Packs/year [if ex-smoker or current smoker]	Numeric [calculated automatically] (No. of cigarettes per day × smoke years/20)
		Electronic cigarette	Yes/No
		Number of refills per day [if electronic cigarette = yes]	Numeric
		Number of years [if electronic cigarette = yes]	Numeric
		Notes
	High alcohol intake	Yes (more than 1 glass per day, if female, more than a 2 glasses per day, if male) No
	High meat intake	Yes (eats red or white meat more than 3 times a week [including raw ham, cooked ham, bresaola]) No
	High intake of salami	Yes (eats cured meats more than once a week [salami, mortadella, sausage, frankfurters …]) No
	Poor vegetable intake	Yes (less than 2 times per day) No (1 serving is considered as a salad plate [at least 50 g] or half a plate of cooked/raw vegetables or a glass of juice/centrifuge)
	Poor fruit intake	Yes (less than 3 whole fruits per day) No (1 whole fruit, such as apple, pear or orange, or 2/3 small fruits, such as apricots plums or fruit salad bowl)
	Notes
Microsatellite instability	Yes/No
	Notes
ALLERGIES AND ADVERSE REACTIONS
Allergies (detail visible only if “Yes” and repeatable)	Yes/No
	Type	Drug MDC Not a Drug
	Active substance/molecule [if drug or MDC allergy]
	Commercial name [if drug or MDC allergy]
	Notes
PREVIOUS adverse reactions (detail visible only if “Yes” and repeatable)	Yes/No
	Date	Month/year [mm/yyyy]
	Description
	Grade	Mild Moderate Severe
	Timing	Early Late
	Notes