Free CRC Screening Test Programme Assessment Please enable JavaScript in your browser to complete this form.Part 1 : Personal Information1. Gender:MaleFemale2. Contact number (Please leave a number with WhatsApp function.):3. E-mail:4. Birth year and date:MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119205. Your education level:Secondary school or belowUniversity graduatePost-graduate or above6. Are you Hong Kong resident?YesNoPart 2 : Your lifestyle7. What is your height?8. What is your weight?9. Do you currently smoke cigarettes?Yes, currentlyNo, but previously have No, never10. Do you drink alcohol? (1 standard drink contains approximately 14 grams of pure alcohol, which is the amount typically found in 355 mL of regular beer, 150 mL of wine, or 45 mL of spirit) Yes, more than 8 standard drinks per weekYes, 5 – 8 standard drinks per weekYes, less than 5 standard drink per weekNo or just occasionally 11. Do you exercise at least 30 minutes per week? YesNoPart 3 : Medical history12. Have you ever been diagnosed of diabetes mellitus?YesNo13. Have you ever been diagnosed of colonic polyps?YesNo14. Have you ever been diagnosed of colonic diarrhoea?YesNo15. Have you ever been diagnosed of colonic constipation?YesNo16. Have you ever discovered blood and/or mucus in the stool?YesNo17. Have any of your biological parents, brothers, sisters, or children been diagnosed with colorectal cancer?YesNo18. Have any of your biological parents, brothers, sisters, or children been diagnosed with any of the following? (Lynch syndrome / Familial adenomatous polyposis (FAP) / MYH-associated polyposis (MAP) / Peutz-Jeghers syndrome (PJS) / Adolescent polyposis)YesNoNext PageUpdating preview…This is your completed forms for preview and it has not been submitted yet! Please take a moment to confirm your personal information is correct and complete, or you can go back and re-fill it.重要事項 免費大腸癌篩查計劃是由華昇診斷中心(下稱Sunrise)支持。 此免費大腸癌篩查計劃是一項由Sunrise與亞洲癌症研究與教育聯盟下稱ACARE的合作項目。 Sunrise會資助大腸癌自采樣檢測服務(下稱「ColoTect」)篩查同ColoTect之後的醫療諮詢服務,而ACARE 則會資助ColoTect之後的醫療諮詢,並負責聘請合格第三方提供所有醫療諮詢服務。 所有參加者皆為自願參與大腸癌自我採樣檢測、醫療諮詢及ColoTect篩查服務。 符合問卷結果評分條件的參加者可免費接受ColoTect篩查服務和ColoTect後的醫療諮詢。 在進行ColoTect篩查後,若醫護人員按參加者的狀況提出了任何後續建議,參加者可自行選擇是否接納,同時亦是由參加者自行承擔這些建議的費用和風險。 由於ColoTect篩查服務和ColoTect之後的醫療諮詢的免費名額有限,並非所有高風險參加者在完成此大腸癌風險評估問卷後會得到免費ColoTect篩查服務及ColoTect 之後的醫療諮詢。 未能得到免費ColoTect篩查服務或醫療諮詢的參加者可自行選擇是否進行ColoTect篩查,同時亦是由參加者自行承擔進行ColoTect篩查的費用和風險。 符合條件的參加者,ACARE會主動透過電話或Whatsapp聯絡參加者並安排免費的ColoTect篩查服務和ColoTect後的醫療諮詢。 若符合條件的參加者因任何原因而未能或錯失了免費的ColoTect篩查服務或ColoTect後的醫療諮詢,Sunrise或ACARE將不會對參加者的任何損失承擔任何責任。 如果參加者在ACARE主動聯繫後無法取得回應,則參加者被視為主動放棄這次免費 ColoTect 篩查服務,亦不會得到任何未使用的服務的退款。 參加者同意及允許Sunrise或ACARE在未來可刊登或公佈大腸癌風險評估結果、ColoTect篩查結果、病史等的匯總數據。 醫療諮詢或會由普通科醫生、家庭醫學專科醫生、腸道科專科醫生或臨床腫瘤科專科醫生進行。 此大腸癌風險評估問卷是根據數個國際研究起擬,並已由本地醫護人員審閱。 此大腸癌風險評估的計算是按參加者提供的答案來作評估,評估結果或未能完全代表個別參加者患上大腸癌的風險。 經評估為高風險的參加者並不代表現時或將來有機會患上大腸癌,同樣地,經評估為低風險的參加者現時或將來或有機會患上大腸癌。 此大腸癌風險評估的結果只作參考之用,Sunrise或ACARE將不會對參加者因假陽性或假陰性的任何後果承擔任何責任,同時亦不對在ColoTect篩查服務或ColoTect之後的醫療諮詢期間提供的任何諮詢或建議負責。 .如參加者就ColoTect及大腸癌風險評估有任何疑問,是由參加者自行負責在參與此大腸癌免費篩查計劃前向醫生查詢。 個人資料私隱政策聲明 參加者可自行決定是否提供資料以參加這個大腸癌風險評估。 華昇診斷中心有限公司會將參加者的大腸癌風險評估結果轉移至亞洲癌症研究與教育聯盟作後續醫療諮詢服務安排之用。 如參加者不欲將其大腸癌風險評估結果轉移至亞洲癌症研究與教育聯盟,請以電郵通知華昇診斷中心,並註明「致華昇診斷中心私隱專員」(電郵地址:info@sunrisediagnostic.com.hk)。 華昇診斷中心會於接獲有關要求之日起40天內作出回覆。 如華昇診斷中心未能於前述限期內處理有關要求,華昇診斷中心應於前述限期內通知參加者。 然而,參加者將自動放棄後續大腸癌篩查及醫療諮詢服務(如適用)。 上述用途均需符合華昇診斷中心有限公司私隱政策聲明,該聲明可參閱本網站底部的私隱政策聲明,或透過向本公司以電郵索取,並註明「致華昇診斷中心私隱專員」(電郵地址:info@sunrisediagnostic.com.hk)。 本人已詳細閱讀上述個人資料私隱政策聲明、免費大腸癌篩查計劃評估網站的私隱政策聲明及上述重要事項,並確認本人完全明白及同意有關內容。 Important Notes This free colorectal cancer screening program is supported by Sunrise Diagnostic Centre (hereinafter referred to as Sunrise). This free colorectal cancer screening program is a collaborative project between Sunrise and Asian Cancer Alliance for Research and Education (ACARE). Sunrise will subsidize the colorectal cancer self-sampling and testing service (referred to as "ColoTect") screening and medical consultation after ColoTect, while ACARE funds the post-ColoTect medical consultation, and is responsible for engaging qualified third parties to provide all medical consultation. All participants voluntarily participate in the colorectal cancer self-sampling testing, medical consultation, and ColoTect screening services. Eligible participants who meet the scoring conditions of the questionnaire results may receive the ColoTect screening service and post-ColoTect medical consultation free of charge. If there are subsequent follow-up recommendations by the healthcare professional according to the participant's condition after the ColoTect screening, the participant can choose whether to accept them or not, and the participant shall bear the cost and risk of these recommendations. Due to the limited free quota of the ColoTect screening service and post-ColoTect medical consultation, not all high-risk participants will receive free ColoTect screening service and post-ColoTect medical consultation after completing this colorectal cancer risk assessment questionnaire. Participants who do not receive free ColoTect screening services or medical consultations may choose whether to undergo ColoTect screening at their own cost and risk. For eligible participants, ACARE will take the initiative to contact the participants by phone or Whatsapp and arrange free ColoTect screening service and post-ColoTect medical consultation. Sunrise or ACARE will not be liable for any loss to the participant if the eligible participant fails or misses the free ColoTect screening service or post-ColoTect medical consultation for any reason. If ACARE does not receive a response from the participant after contact, the participant will be deemed to have voluntarily given up the free ColoTect screening service and will not receive any refund for the unused service. Participants hereby consent and agree to allow Sunrise or ACARE to publish or publish aggregated data on colorectal cancer risk assessment results, ColoTect screening results, medical history, etc. in the future. Medical consultation may be conducted by a general practitioner, a family medicine specialist, a gastroenterologist, or a clinical oncologist. This colorectal cancer risk assessment questionnaire is based on several international studies and has been reviewed by local medical professionals. The calculation of this colorectal cancer risk assessment is based on the answers provided by the participants. The assessment results may not fully represent the risk of colorectal cancer for individual participants. Participants who are assessed as high risk may not represent a current or future chance of developing colorectal cancer. Similarly, participants who are assessed as low risk may currently or will have a chance of developing colorectal cancer. The results of this colorectal cancer risk assessment are for reference only. Sunrise or ACARE will not take any responsibility for the participants due to any consequences of false positives or false negatives and will not be responsible for the ColoTect screening service or any advice or advice given during the consultation after the ColoTect screening service. If the participant has any questions about ColoTect or the colorectal cancer risk assessment, it is the participant's responsibility to check with the doctor before participating in this free colorectal cancer screening program. Personal Data Privacy Policy Statement Participants can decide whether to provide information to participate in this colorectal cancer risk assessment. Sunrise Diagnostic Centre Limited will transfer the colorectal cancer risk assessment results of the participants to the Asian Cancer Alliance for Research and Education for follow-up medical consultation service arrangements. If participants do not wish to transfer their colorectal cancer risk assessment results to the Asian Cancer Alliance for Research and Education, please notify Sunrise Diagnostic Centre by email, and indicate "To the Privacy Commissioner of Sunrise Diagnostic Centre" (email address: info@ sunrisediagnostic.com.hk). Sunrise Diagnostic Centre will reply within 40 days from the date of receipt of the request. If Sunrise Diagnostic Centre fails to process the relevant request within the specified timeframe, Sunrise Diagnostic Centre shall notify the participants within the specified timeframe. However, participants will automatically waive subsequent colorectal cancer screening and medical consultation services (if applicable). The above uses are subject to the privacy policy statement of Sunrise Diagnostic Centre Limited, which can be found at the bottom of this website. Commissioner” (email address: info@sunrisediagnostic.com.hk). I have read the above Personal Data Privacy Policy Statement, the Privacy Policy Statement of the Free CRC Screening Test Programme Assessment Website, and the above important matters in detail and confirm that I fully understand and agree to the relevant contents. Previous pageSUBMIT