MYCRC Risk Assessment Tool Code Gender Male Female 1- Age (years) [45-85] 2- Ethnicity Hawaiian Japanese Latino White 3- Pack Years of Smoking (years) [0-50] 4- Average Number of Alcoholic Drinks (drinks per day) [0-12] 5- Weight (lb) [75-350] 6- Height (inches) [60-80] 7- Years of Education (years) [6-20] 8- Family History of Colon Cancer Yes No 9- Regular Use of Multivitamins Yes No 10- Ounces of Red Meat Intake per Day (ounces per day) [0-5] 11- History of Diabetes Yes No 2-12- How many separate colorectal cancers do you have? None One Two or more 3-12- If one, what was the age at diagnosis? If two or more, what was the youngest age at diagnosis? (If unknown, please estimate) 1-13- Has the patient had endometrial (uterine) cancer? Yes No 2-13- If so, what was the age at diagnosis? (If unknown, please estimate) 14- Has the patient had any other Lynch syndrome-associated cancer? Other Lynch syndrome-associated cancers include ovary, stomach, small intestine, urinary tract/bladder/kidney, bile ducts, brain, pancreas, and sebaceous gland skin tumors. Yes No Relatives: First-degree First-degree relatives include parents, siblings, children, only from affected side of family 1-15- How many first-degree relatives have had colorectal cancer? None One Two or more 2-15- If one, what was the age at diagnosis? If more than one, what was the youngest age at diagnosis? (If unknown, please estimate) 1-16- How many first-degree relatives have had endometrial (uterine) cancer? None One Two or more 2-16- If one, what was the age at diagnosis? If more than one, what was the youngest age at diagnosis? (If unknown, please estimate) 17- Have any first-degree relatives had other Lynch syndrome-associated cancers? Other Lynch syndrome-associated cancers include ovary, stomach, small intestine, urinary tract/bladder/kidney, bile ducts, brain, pancreas, and sebaceous gland skin tumors. Yes No Relatives: Second-degree Second-degree relatives are grandparents, grandchildren, aunts, uncles, nieces, nephews, only from affected side of family 1-18- How many second-degree relatives have had colorectal cancer? None One Two or more 2-18- If one, what was the age at diagnosis? If more than one, what was the youngest age at diagnosis? (If unknown, please estimate) 1-19- How many second-degree relatives have had endometrial (uterine) cancer? None One Two or more 2-19- If one, what was the age at diagnosis? If more than one, what was the youngest age at diagnosis? (If unknown, please estimate) 20- Have any second-degree relatives had other Lynch syndrome-associated cancers? Other Lynch syndrome-associated cancers include ovary, stomach, small intestine, urinary tract/bladder/kidney, bile ducts, brain, pancreas, and sebaceous gland skin tumors. Yes No (Just for Men) 21- Regular Use of Aspirin Yes Yes - Not Currently No 22- Hours of Moderate Physical Activity per Day (hours per day) [0-4] (Just for Women) 21- Regular Use of NSAIDs Yes, currently Yes, but not currently 22- Have you used Estrogen? Yes-currently Yes-previously Calculate
