Men's Cancer Risk Assessment Form
Complete this form to share general risk factors and background information for a men's cancer risk assessment.
Respondent & Screening Information
Full Name
First Name
Middle Name
Last Name
Age
*
Contact Email
*
example@example.com
Primary Reason for Assessment
Routine screening
Family history concerns
Symptoms
Doctor referral
Other
Risk Factors & Medical Background
Family history of cancer
*
No
Yes
Unsure
Smoking status
*
Please Select
Never
Former
Current
Occasional
Prefer not to say
Alcohol use frequency
*
Please Select
Never
Monthly or less
2-4 times per month
2-3 times per week
4 or more times per week
Prefer not to say
History of high-risk medical conditions or prior diagnoses
History of abnormal screening results
Prior precancerous condition
Chronic inflammatory condition
Prior cancer diagnosis
Other relevant condition
None of the above
Any concerning symptoms or changes
Lifestyle & Assessment Notes
Physical activity level
*
Sedentary
Lightly active
Moderately active
Very active
Other
Additional comments
Submit Assessment
Should be Empty: