SPOT CANCER RISK
(uL)'
Patient Chart No. - - - -__
QUESTIONNAIRE
CA'.CE:R RISK
Name - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Date of Birth - - - - - - - -
FOR MEN ONLY
PROSTATE CANCER
TESTICULAR CANCER
YES NO
YES NO
o0
o0
o0
o
0
o
I have had testicular cancer.
I am between the ages of 15 - 45.
I have had an undescended testicle.
I have one testicle which is smaller (atrophied)
than the other
00
DO
DO
DO
I have light colored hair, eyes or complexion.
I have a large number of Mmoles• or moles that are
large or irregular in shape or color.
I was sunburned (blistered) several times before
age 20.
My skin is frequently exposed to chemicals or
o
o
I have had a vasectomy. When?
YES NO
o
o
0
0
o
o
I have smoked cigarettes.
date guit?
0
I am over 40 years of age.
0
I am exposed to other people's cigarette smoke.
D 0
)
At work, I am exposed to arsenic, asbeetor.
chromates, nickel, petroleum, or uranium.
00
Someone in my family has had lung cancer.
------------GENERAL HEALTH
I have had cancer.
D O There is a history of cancer in my immediate family.
I have had colon cancer.
A family member has had colon cancer.
_
I have had Crohn's disease or ulcerative colitis.
0
I have had a recent change from my usual bowel
movements.
I have noticed blood in my bowel movements.
I am over 50 years of age.
I smoke cigarettes.
(How long?
YES NO
0
0
0
_
I am black.
Who?
D O l have had polyp(s) in the colon.
o
o
D
D
I have been to tanning salons.
Who?
o
Who?
D 0
I have a family history of skin cancer.
YES NO
0
0
Someone in my family had prostate cancer.
I frequently work or play in the sun.
COLON CANCER
o
0
LUNG CANCER
radioactive materials (arsenic, coal, petroleum,
uranium, radioisotopes).
DO
DO
o
I am over 50 years of age.
SKIN CANCER
YES NO
DO
o
o
0
DO I am 15 or more pounds overweight.
DO I eat a diet high in fat content.
DO I eat fewer that 5 servings of fruit and vegetables per
day.
DO I use chewing tobacco or snuff.
DO I have not had a complete physical in at least five
years.
DO I drink alcohol regularly.
DO
I have not been to a dentist in over three years.
A joint program developed and funded bt The University of Texas M. D. Anderson Cancer Center and the Texas Academy of Family Physicians.
SPOT CANCER RISK
YUUR CANCER RISK
Name
Patient Chart No. - - - - - -
QUESTIONNAIRE
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - Date of Birth ---------
FOR WOMEN ONLY
CERVICAL CANCER
BREAST CANCER
YES NO
o
o
0
0
YES NO
I have had breast cancer.
Someone in my family has had breast cancer.
Who?
o
o
o
o
o
0
0
0
0
0
I am over 50 years of age.
I have had surgery for -lumps· in the breast.
I have had a female cancer (womb or ovary).
I gave birth to my first child after age 35.
I am 35 years old or older and have not been
pregnant to full term (9 months).
00
DO
DO
I have light colored hair, eyes or complexion.
I have a large number of "moles" or moles that are
I was sunburned (blistered) several times before
age 20.
My skin is frequently exposed to chemicals or
radioactive materials (arsenic, coal, petroleum,
uranium, radioisotopes).
I have a family history of skin cancer.
o0
o0
o
o
o
o
0
0
0
0
I have had genital warts.
I smoke cigarettes.
I have a history of bleeding after intercourse or
between periods.
YES NO
I have had colon cancer.
A family member has had colon cnacer.
'"--
_
I have had polyp(s) in the colon.
I have had Crohn's disease or ulcerative colitis.
I have had a recent change from my usual bowel
movements.
I have noticed blood in my bowel movements.
I am over 50 years of age.
I smoke cigarettes.
I have smoked cigarettes.
DO
DO
DO
DO
DO
DO
DO
DO
DO
date guit?
)
I am over 40 years of age.
I am exposed to other people's cigarette smoke.
At work, I am exposed to arsenic, asbestor,
chromates, nickel, petroleum, or uranium.
Someone in my family has had lung cancer.
Who?
I have been to tanning salons.
Who?
DO
DO
I began intercourse before age 18.
(How long?
YES NO
DO
DO
DO
I have had more than 1 sexual partner.
YES NO
I frequently work or play in the sun.
COLON CANCER
DO
DO
It has been longer than one year since my last pap
smear.
LUNG CANCER
large or irregular in shape or color.
DO
DO
00
I have had an abnormal pap smear.
SKIN CANCER
YES NO
DO
DO
......-_
DO
DO
DO
DO
DO
DO
------------......-GENERAL HEALTH
I have had cancer.
There is a history of cancer in my immediate family.
I am 15 or more pounds overweight.
I eat a diet high in fat content.
I eat fewer that 5 servings of fruit and vegetables per
day.
I use chewing tobacco or snuff.
I have not had a complete physical in at least five
years.
I drink alcohol reglJlarly.
I have not been to a dentist in over three years.
A joint program developed and funded by The University of Texas M.D., Anderson Cancer Center and the Texas Academy of Family Physicians.