Oral Cancer Risk Assessment Form
Screen your risk for oral cancer by answering the following health-related questions.
What is your age group?
*
Under 30
30-44
45-59
60 or older
Do you currently use tobacco products (smoking or smokeless)?
*
Never
Former user
Occasionally
Daily
How often do you consume alcoholic beverages?
*
Never
Occasionally (1-3 times/month)
Weekly (1-6 times/week)
Daily
Have you noticed any persistent sores, white or red patches, or lumps in your mouth?
*
No
Yes, for less than 2 weeks
Yes, for more than 2 weeks
Do you have a personal or family history of oral or head and neck cancer?
*
No
Yes, personal history
Yes, family history
How would you rate your oral hygiene practices?
*
1
2
3
4
5
How often do you visit a dentist for a check-up?
*
At least once a year
Every 2-3 years
Less often
Never
Have you ever been diagnosed with human papillomavirus (HPV) or had an HPV-related lesion?
*
No
Yes
Not sure
How frequently are you exposed to direct sunlight on your lips (outdoor work or activities)?
*
Rarely
Occasionally
Frequently
Please indicate how often you consume the following foods:
*
Rows
Never
Occasionally
Frequently
Raw fruits and vegetables
1
2
3
Processed meats
4
5
6
Spicy or salty foods
7
8
9
Submit Assessment
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