SCREENING QUESTIONNAIRE (ORAL, CERVICAL, BREAST CANCER)
Name
Gender- □ Male □ Female
Age
1. Have you ever been diagnosed with cancer? □ Yes □ No
2. Has anyone in your family been diagnosed with cancer? □ Yes □ No
3. Do you smoke (cigarette or bidi)? □ Yes □ No
a. If yes, how many cigarettes do you usually smoke in a day?
- 14 or Fewer
- Between 15 and 25
- More than 25
4. Do you consume tobacco? □ Yes □ No
If yes, how often do you consume tobacco?
- Regularly (several times in a day)
- Sometimes
- Rarely
5. Do you consume alcohol?
If yes, how often do you consume alcohol? □ Yes □ No
- Regularly (everyday)
- Sometimes
- Rarely
6. Do you have patches on lining of the mouth/tongue, usually red or red and white in color?
□ Yes □ No
7. Is there any lump or thickening of the skin or lining of the mouth? □ Yes □ No
8. Has your swelling persisted for over 3 weeks? □ Yes □ No
9. Do you have ulcers or sores that do not heal? □ Yes □ No
10. Are there any loose teeth with no clear reason? □ Yes □ No
11. Is there any pain when swallowing? □ Yes □ No
12. Is there a sensation that something is stuck in the throat? □ Yes □ No
13. Do you have hoarse voice? □ Yes □ No
14. Do you feel any pain in the neck or ear that does not go away? □ Yes □ No
If the respondent is FEMALE, continue to ask following questions-
15. How old were you at the time of your first menstrual period?
- Under 12 years of age
- 12 years or older
16. How many children have you given birth to (include still-births and abortions/miscarriages)?
- None
- One or more
17. How old were you at the time of first live birth?
- Under 30
- 30 years or above
18. Has your mother, sister, or daughter ever been diagnosed with breast cancer?
□ Yes □ No □ Do not know
19. Have you ever had a mammogram? □ Yes □ No □ Do not know
If yes,
When was the mammogram done? _______________________
Where was the mammogram done? ____________________
What were the results?
20. Have you ever had radiation therapy to the chest for treatment of a disease? □ Yes □ No
21. Have you ever been tested and found to have a gene mutation linked to breast cancer?
□ Yes □ No
22. Do / did you ever use oral contraceptive pills (OCP)?
- No
- Yes, I am currently taking OCP
- Yes, I have used OCP in the past but not taking now
If yes, for how many years have you used the OC pills? ..........................................................
23. Have you gone through menopause (stopped having menstrual periods for at least past 12
months)? □ Yes □ No
If yes, was it-
- Before age 55
- 55 or later
24. Have you ever had hysterectomy? □ Yes □ No
25. How old were you when you first had sex?
- Younger than 16 years
- 16 years or Older
26. How many sexual partners have you had in your life?
- 1 or 2
- 3 or more
27. Do you regularly use condoms or diaphragms while sexual intercourse?
- Yes, almost always
- Sometimes
-Never
28. Have you ever had a sexually transmitted infection (STI) also known as a sexually transmitted
disease or STD? (like human papillomavirus virus (HPV), genital herpes, gonorrhea, chlamydia,
HIV/AIDS)
- Yes
- No
-Don’t know
29. Have you had a Pap test (also known as a Pap smear) within the last 3 years? □ Yes □ No
If yes, when was the Pap test done? _______________________
Who did the Pap test? ____________________
What were the results? ____________________
30. Have you been vaccinated against HPV (that is, been given Gardasil® or Cervarix®)?
□ Yes □ No □ Do not know
