A. Skin Yes
No
1.
Do you have a mole that has bled or changed in
color, size or shape in the past few months?
2.
Do you have a sore that has not healed in more
than a month?
3.
Have you noticed any skin changes in an area
where you had x-ray treatments?
4.
Have you noticed a scar from a bad burn which
happened over a year ago?
5.
Do you have a mole on the palm of your hand,
sole of your foot, or on the genitals, or in a place where it may be easily irritated?
6.
Do you have fair skin and/or sunburn easily?
7.
Do you spend a great deal of time in the sun
because of your work or recreational activities?
8.
Do you have a family history of melanoma?
B. Head and Neck (includes larynx, thyroid,
mouth and throat) Yes
No
1.
Have you had hoarseness or any change in your
voice that has lasted for longer than a month?
2.
Have any of your blood relatives ever had cancer
of the larynx, mouth or throat?
3.
Do you have pressure or tightness in the lower
front of your neck that has lasted more than a month?
4.
From childhood through young adulthood, did you
have a series of x-ray treatments to the front of your neck for acne, neck tumor or any
other reason?
5.
Do you have pain or difficulty in swallowing
which as lasted more than a month?
6.
Do you have pain or tenderness in your mouth
which as lasted more than a month?
7.
Do you have a sore or white spot on your tongue,
lips, cheeks, or gums which has lasted longer than a month?
8.
Do you have dentures or a tooth which irritates
your tongue, cheeks, or gums?
9.
Do you now smoke?
10.
Do you use chewing tobacco or snuff?
11.
Do you drink more than 3 alcoholic beverages per
day?
C. Lungs Yes
No
1.
Do you smoke?
2.
If not, have you ever smoked on a regular basis?
3.
In the past few weeks, have you coughed up
blood?
4.
Do you have a daily cough that has lasted more
than one month?
5.
Do you have emphysema?
6.
Have any of your blood relatives ever had cancer
of the lung?
D. Digestive System Yes
No
1.
Have you lost more than 10 pounds in the past
few months unrelated to eating habits or exercise?
2.
Have you vomited blood in the past six months?
3.
Have you had a change in your bowel habits in
the past few months and/or noticed black or tarry stools?
4.
Have you had bleeding from the rectum, either
with bowel movements or at other times?
5.
Do you have frequent aches or pain in the
abdomen for which you do not know the reason?
6.
Has a doctor ever told you that you had Crohn's
Disease, pernicious anemia, or ulcerative colitis?
7.
Do you have intestinal or rectal polyps?
8.
Have any of your blood relatives had cancer of
the stomach or colon?
9.
Are you over the age of 40?
E. Kidney and Bladder Yes
No
1.
Have you noticed blood in your urine in the past
few weeks?
2.
Have you felt pain or burning on urination in
the past few weeks?
3.
Have any of your blood relatives ever had cancer
of the kidneys or bladder?
F. Occupational and Environmental Exposure Yes
No
1.
Have you ever or do you now work with or near
industrial chemicals or hazardous materials such as asbestos, nickel, uranium, chromates,
petroleum or vinyl chloride?
2.
Are you exposed to cadmium in your work place?
(men only)
3.
Do you work in the leather, rubber or dye
industry?
G. Breasts (Females) Yes
No
1.
Do you have pain in the breasts for which you do
not know the reason?
2.
Have you noticed a lump in either breast?
3.
Have you noticed any change in your nipples
lately?
4.
Have you noticed any discharge, bleeding or
scaling of the nipples?
5.
Have you noticed any change in the skin of your
breasts such as dimpling, puckering or color change?
6.
Have any of your blood relatives had cancer of
the breast?
7.
If you have had a baby, was the first delivery
after you were thirty years of age?
8.
Are you over the age of 50?
H. Female Reproductive Yes
No
1.
Do you have vaginal bleeding or spotting for
which you do not know the reason?
2.
Are you on female hormone therapy?
3.
Have any of your blood relatives had cancer of
the uterus and/or ovaries to your knowledge?
4.
Has a doctor ever told you that you had genital
warts?
5.
Do you consider yourself to be overweight?
6.
Have you had a hysterectomy?
7.
Did you first have sex before the age of 18?
8.
Have you had two or more sexual partners in a
year?
9.
Are you infertile and/or have you never had a
baby? (if either statement is true, answer yes)
I. Male Reproductive Yes
No
1.
Do you have pain or swelling in either testicle
that has lasted more than one month?
2.
Do you have difficulty in starting to urinate?
3.
Do you have an undescended or missing testicle?
4.
Do you have an enlarged prostate?
5.
Have any of your blood relatives had cancer of
the testes or prostate to your knowledge?
J. Diet and Nutrition Yes
No
1.
Do you eat high-fat meat (steak, ground beef,
hot dogs, chuck roast) on a daily basis?
2.
Do you eat smoked and/or cured meat and fish as
much as four times per week?
3.
Do you rarely eat poultry and fish?
4.
Do you eat baked goods such as cookies, cake,
sweet rolls, donuts and pies five or more times per week?
5.
Do you eat snacks such as buttered popcorn,
candy bars, potato chips and nuts every day?
6.
Do you eat fried foods three or more times per
week?
7.
Do you add salad dressing, mayonnaise, sour
cream, butter or margarine when preparing food or at the table?
8.
Do you eat foods with beta-carotene and Vitamins
A and C such as sweet potatoes, green leafy vegetables, tomatoes, melons, carrots, citrus
fruits, broccoli, cabbage, cauliflower, and brussel sprouts less than once a day?
9.
Do you use dairy products such as whole milk,
ice cream, and high-fat cheese on a daily basis?
10.
Do you eat whole grain foods and cereals less
than once a day?
11.
Are you more than 20 pounds over your ideal
weight?
