Patient Self Assessment
Cancer Screening

Everyone is at risk for developing cancer. Certain cancers are preventable or can be screened for and detected early.
Education and information about how you can prevent and control cancer is essential to your overall health. The purpose of this patient tool is to educate and inform participants about cancer screening recommendations. You will be asked some simple questions that generally assess your risk for colorectal, lung and skin cancer. If you are female you will answer questions for breast and cervical cancer risk and if you are male questions about prostate cancer risk can be completed. This tool should not be used for diagnostic purposes. Please discuss any health concerns with your physician. The survey will take 5-10 minutes to complete and should be done in one sitting because the information will not be saved. Then print out your results and discuss with your health care professional.

Please answer the following questions:

1. Your present age is Under 20 20-39 40-49 50+

2. Your current height in inches is

3. Your current weight in pounds is

This is your Body Mass Index calculated from the above infomation. 0.00

4. Your gender is Female Male

5. Race is
White American Indian and Alaska Native Native Hawaiian and Other Pacific Islander
Black or African American Asian Some other race


6. Your ethnicity is

7. Alcohol - One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one
shot of liquor. During the past 30 days, on the days when you drank, how many drinks did
you have on average? 0 1 2 3 4 5 6

8. Have you smoked at least 100 cigarettes in your entire life or do you currently smoke cigarettes, every day or some days, or use other tobacco products? Yes No

______________________________________________________________________________________________________

Lung Cancer:

1. Do you use tobacco products? Yes No

2. Are you constantly exposed to second-hand
smoke either at home or at work? Yes No

3. To your knowledge, have you been exposed to asbestos? Yes No

4. Have you heard of Radon? Yes No

5. Are you aware radon may cause lung cancer? Yes
No

6. Has your home been tested for radon? Yes No

7. What is the lowest live-in level in your home? Basement First floor

8. Does someone in the household sleep on that level or use it daily? Yes No

9. How long have you lived in your current house?

10. Do you or anyone in the household smoke? Yes No

11. Your county may have a greater or lesser potential for elevated radon. What county in Kansas do you live in?


12. Would you like information on radon testing? Yes No




_______________________________________________________________________________________________________

Skin Cancer:

1. Do you have blue-green eyes? Yes No

2. Do you burn easily? Yes No

3. Do you work outdoors or participate in outdoor activities for more than 30 minutes between the hours
of 10 am and 4 pm? Yes No

4. Do you use tanning beds? Yes No

5. Have you ever had a blistering sunburn? Yes No

6. Have you ever had a wart or mole that has ulcerated or bled? Yes No


_________________________________________________________________________________________

Survey completed, click here for results and recommendations