Questionnaire for Risk Profiling
The purpose of this questionnaire is to ascertain the risk of cancer. Information provided by you will be kept confidential.
Email *
Name *
Mobile Number *
General :
1. Age *
2. Gender *
3. Personal / Family History of Cancer
4. Habits
Specific:
Liver :
1. Do you consume Alcohol
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a.    If Yes
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2. History of Jaundice
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3. Have you been diagnosed with any Liver disease
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Gastrointestinal General :
1. Recent loss of Weight
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2. Recent loss of Appetite

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3. Change in bowel habits – Constipation or Diarrhea

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4. Any bleeding in Stool or black Stool

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5. Difficulty in Eating

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Head & Neck and Thorax :
1. Habit of Smoking 
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2. Tobacco or Pan parag, Ghutka, Betel nut chewing
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3. White or Red patch in Cheek
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4. Change of Voice or chronic Cough
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5. Neck Swelling
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