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CAP Movement Survey
To collate data of cancer patients for study and research purpose to find the etiology and to fight the root cause.
Also will try to mobilize financial help for those who are needy.
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Cancer Awareness & Prevention Survey
1.
Full Name
*
Your answer
2.
Age
*
Your answer
3.
Gender
*
Female
Male
Other:
4.
Occupation
Your answer
5.
Address/Place/District
*
Your answer
6.
State
*
Your answer
7.
Contact Number
*
Your answer
8.
Diagnosed Date
MM
/
DD
/
YYYY
9.
Type of Cancer
Your answer
10.
Stage
Your answer
11.
Treatment
Chemotherapy
Radiation
Operation
Alternative therapy
Other:
Clear selection
12.
Family history of cancer
yes
No
Clear selection
13.
Details of breast feeding (applicable only for female breast cancer patients)
Less than three months
Continues till six months
Not Applicable
Clear selection
14.
Any other illness
Diabetes
Cholesterol
Not applicable
Other:
Clear selection
15.
Any chronic wounds
Yes
No
Clear selection
16. Addiction
Smoking
Alcohol
Tobacco
Not applicable
Other:
17.
Vegetarian
Yes
No
18.
Hotel food consumption
Once or twice a week
Daily
rarely
Not Applicable
Other:
19.
Maida based food consumption (bread, porotta, bakery items etc)
Once or twice a week
Daily
rarely
Not Applicable
Other:
20.
Junk food consumption (Pepsi/cola, Burger/Pizza etc)
Once or twice a week
Daily
rarely
Not Applicable
Other:
21.
Beef Consumption
Daily
Once or twice a Week
Rarely
Not Applicable
22.
Chicken Consumption
Daily
Once or twice a Week
Rarely
Not Applicable
23.
Fish Consumption
Daily
Once or Twice a Week
Rarely
Not Applicable
24.
Other Non-Veg Consumption
Daily
Once or Twice a Week
Rarely
Not Applicable
25.
Dinner timing
After 10 PM
Before 10 PM
Before 8 PM
26.
Breakfast/Lunch/Dinner
Habit of skipping breakfast
Have on proper timing
No Particular timing
Clear selection
27.
Oil using at home
Coconut oil
Refined oil
Other:
Clear selection
28. Physical Activity/Exercise
daily
Once or twice a week
No physical activity
Other:
Clear selection
29. Are you looking for any financial support
Yes
No
Clear selection
30. Any comments or what you think the cause of your disease
Your answer
Submit
Clear form
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