Cancer Risk Assessment

To Complete the questionnaire, please check yes or no to each question. Please consider each question carefully so that your personal profile and advice can be as helpful as possible. This risk assessment is designed to be a guideline to you by identifying certain risk factors and warning signs as well as providing you with action you can take to prevent cancer or to catch cancer at an early stage. The results of this assessment do not in any way signify that you have cancer, will have cancer, or will never have cancer. You are encouraged to follow up on any advice given on your personal printout. It should be noted that this program in no way should replace your regular physical examinations by a physician. For your health's sake, we encourage annual physical exams by a physician. ** It is essential that you fill out the name and address fields so that we can send you your results! **

Name *
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Date / MM / DD YYYY
Sex Male Female
Phone - (###) - ### ####
Race
Age
Do you Smoke ? Yes No
Are you overweight? Yes No
Do you presently have a personal physician? Yes No
A. Skin
1. Do you have a mole that has bled or changed in color, size or shape in the past few months? Yes No
2. Do you have a sore that has not healed in more than a month? Yes No
3. Have you noticed any skin changes in an area where you had x-ray treatments? Yes No
4. Have you noticed a scar from a bad burn which happened over a year ago? Yes No
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? Yes No
6. Do you have fair skin and/or sunburn easily? Yes No
7. Do you spend a great deal of time in the sun because of your work or recreational activities? Yes No
8. Do you have a family history of melanoma? Yes No
B.Head and Neck (includes larynx, thyroid, mouth and throat)
1. Have you had hoarseness or any change in your voice that has lasted for longer than a month? Yes No
2. Have any of your blood relatives ever had cancer of the larynx, mouth or throat Yes No
3. Do you have pressure or tightness in the lower front of your neck that has lasted more than a month? Yes No
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? Yes No
5. Do you have pain or difficulty in swallowing which as lasted more than a month? Yes No
6. Do you have pain or tenderness in your mouth which as lasted more than a month? Yes No
7. Do you have a sore or white spot on your tongue, lips, cheeks, or gums which has lasted longer than a month? Yes No
8. Do you have dentures or a tooth which irritates your tongue, cheeks, or gums? Yes No
9. Do you now smoke? Yes No
10. Do you use chewing tobacco or snuff? Yes No
11. Do you drink more than 3 alcoholic beverages per day? Yes No
C.Lungs
1. Do you smoke? Yes No
2. If not, have you ever smoked on a regular basis? Yes No
3. In the past few weeks, have you coughed up blood? Yes No
4. Do you have a daily cough that has lasted more than one month? Yes No
5. Do you have emphysema? Yes No
6. Have any of your blood relatives ever had cancer of the lung? Yes No
D.Digestive System
1. Have you lost more than 10 pounds in the past few months unrelated to eating habits or exercise? Yes No
2. Have you vomited blood in the past six months? Yes No
3. Have you had a change in your bowel habits in the past few months and/or noticed black or tarry stools? Yes No
4. Have you had bleeding from the rectum, either with bowel movements or at other times? Yes No
5. Do you have frequent aches or pain in the abdomen for which you do not know the reason? Yes No
6. Has a doctor ever told you that you had Crohn's Disease, pernicious anemia, or ulcerative colitis? Yes No
7. Do you have intestinal or rectal polyps? Yes No
8. Have any of your blood relatives had cancer of the stomach or colon? Yes No
9. Are you over the age of 40? Yes No
E. Kidney and Bladder
1. Have you noticed blood in your urine in the past few weeks? Yes No
2. Have you felt pain or burning on urination in the past few weeks? Yes No
3. Have any of your blood relatives ever had cancer of the kidneys or bladder? Yes No
F. Occupational and Environmental Exposure
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? Yes No
2. Are you exposed to cadmium in your work place? (men only) Yes No
3. Do you work in the leather, rubber or dye industry? Yes No
G. Breasts (Females)

1. Do you have pain in the breasts for which you do not know the reason? Yes No

2. Have you noticed a lump in either breast? Yes No

3. Have you noticed any change in your nipples lately? Yes No

4. Have you noticed any discharge, bleeding or scaling of the nipples? Yes No

5. Have you noticed any change in the skin of your breasts such as dimpling, puckering or color change? Yes No

6. Have any of your blood relatives had cancer of the breast? Yes No

7. If you have had a baby, was the first delivery after you were thirty years of age? Yes No

8. Are you over the age of 50? Yes No

H. Female Reproductive

1. Do you have vaginal bleeding or spotting for which you do not know the reason? Yes No

2. Are you on female hormone therapy? Yes No

3. Have any of your blood relatives had cancer of the uterus and/or ovaries to your knowledge? Yes No

4. Has a doctor ever told you that you had genital warts? Yes No

5. Do you consider yourself to be overweight? Yes No

6. Have you had a hysterectomy? Yes No

7. Did you first have sex before the age of 18? Yes No

8. Have you had two or more sexual partners in a year? Yes No

9. Are you infertile and/or have you never had a baby? (if either statement is true, answer yes) Yes No

I. Male Reproductive

1. Do you have pain or swelling in either testicle that has lasted more than one month? Yes No

2. Do you have difficulty in starting to urinate? Yes No

3. Do you have an undescended or missing testicle? Yes No

4. Do you have an enlarged prostate? Yes No

5. Have any of your blood relatives had cancer of the testes or prostate to your knowledge? Yes No

J. Diet and Nutrition

1. Do you eat high-fat meat (steak, ground beef, hot dogs, chuck roast) on a daily basis? Yes No

2. Do you eat smoked and/or cured meat and fish as much as four times per week? Yes No

3. Do you rarely eat poultry and fish? Yes No

4. Do you eat baked goods such as cookies, cake, sweet rolls, donuts and pies five or more times per week? Yes No

5. Do you eat snacks such as buttered popcorn, candy bars, potato chips and nuts every day? Yes No

6. Do you eat fried foods three or more times per week? Yes No

7. Do you add salad dressing, mayonnaise, sour cream, butter or margarine when preparing food or at the table? Yes No

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? Yes No

9. Do you use dairy products such as whole milk, ice cream, and high-fat cheese on a daily basis? Yes No

10. Do you eat whole grain foods and cereals less than once a day? Yes No

11. Are you more than 20 pounds over your ideal weight? Yes No

Cancer Risk Assessment

A. Skin

B.Head and Neck (includes larynx, thyroid, mouth and throat)

C.Lungs

D.Digestive System

E. Kidney and Bladder

E. Kidney and Bladder

F. Occupational and Environmental Exposure

G. Breasts (Females)

H. Female Reproductive

I. Male Reproductive

J. Diet and Nutrition