Cancer Risk Assessment Survey
Please answer the following questions to help assess your cancer risk.
Full Name
First Name
Last Name
Age
Gender
Male
Female
Other
Prefer not to say
Do you have a family history of cancer?
Yes
No
Not sure
Do you smoke or have you smoked in the past?
Yes, currently
Yes, in the past
No
Do you consume alcohol?
Yes, regularly
Occasionally
No
Do you have a balanced diet?
Yes
No
Sometimes
Do you exercise regularly?
Yes
No
Sometimes
Have you ever been diagnosed with cancer?
Yes
No
Additional Comments or Concerns
Submit
Should be Empty: