Please describe, in English, your questions relating to your potential cancer risk. Then fill up the Cancer Risk Assessment Questionnaire below and summit it to us by clicking the submit button:

General Cancer Risk Assessment Questionnaire

1. Your birthday:

2. Your Height: cm. or inc.

3. Your weight: kg. or lb.

4. What is your ethnic background:

5. Have you ever had any cancer?YesNo 

6. If yes, what type of cancer?

7. If it was "Breast Cancer", please the and submit to us the Breast Cancer Evaluation Form as well, by 

8. When did you last have your stool checked for blood?

9. What was the result? PositiveNegative

10. Have ever had a sigmoidoscopy? YesNo

11. Have ever had a colonoscopy? YesNo

12. If "Yes", when and what were the findings?

13. Do you smoke? YesNo

14. If "Yes", how many years have you smoked?

15. How many packs per day?

16. Are you a former smoker? YesNo

17. If "Yes", when and why did you quit smoking?

18. Do you drink alcoholic beverages? YesNo

19 If "Yes", how many drinks per week?

20. What do you think is your risk of getting cancer?Very lowAverageSomewhat higher than averageMuch higher than average

21. How concerned are you about your risk of getting cancer?Not at allRarely worryOccasionally worryVery worriedWorry constantly

22. Please, describe your feelings about your potential risk of getting Cancer and in what part of your body:

 

Family Medical History
 

23. How many sisters do you have?  

24. How many brothers?

25. How many sisters does your mother have?  

26. How many brothers does your mother have?

27. How many sisters does your father have?

28. How many brothers does your father have?

29. Has anyone in your family had cancer? YesNo

30. If "Yes", please fill the form below commenting if more than one person is involved in a category.

31. If you are a woman, please fill out and submit to us the Breast Cancer Evaluation Form by  , even though you may not have had cancer of the breast
 

32. In order to communicate with you, we need your Personal Identification Number or PIN:  

If you have not a PIN ,please,    to obtain a PIN:

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