Cancer Risk Assessment Questionnaire

Would you say your general health is:*

Excellent Good Fair Poor

What age group do you fall into?*

0-18 years 18-39 years 40-60 years 60+ years

Do you currently smoke cigarettes, cigars, a pipe, a hookah, or use snuff?*

No, I‘ve never smoked/used tobacco Yes, 2-3 times a week No, I previously smoked/used tobacco regularly, but I quit in the last year Yes, daily

If you do smoke/use tobacco, how many times a day do you do

Never 1-5 times More than 15 times Still smoking

If ever, for how many years did you smoke/use tobacco?

Never/less than a year 1-5 years More than 5-10 years More than 10 years

What is your current weight range?*

Normal >10 kg overweight 10-20 kg overweight >20 kg overweight

About how many cups of vegetables do you eat daily? (1 cup of vegetables = 1 cup of raw or cooked vegetables, 1 cup of 100% vegetable juice, or 2 cups of raw, leafy greens)*

3 or more cups daily 1 cup daily 3-4 cups weekly Once or twice a week

How frequently do you include high fibre (whole grain food, whole grain cereals, beans and legumes) in your diet?*

More than once daily At least once daily At least 4 times weekly Once or twice a week

About how many cups of fruit do you eat daily? (1 cup of fruit = 1 small fruit, 1 cup of 100% fruit juice, or 1/2 cup dried fruit)*

3 or more cups daily 2 cups daily 3-4 cups weekly Once or twice a week

How often do you eat high-fat foods? (Fried foods, fatty meats, packaged foods high in fat, snacks, added fat like oil)*

Rarely or never 3-5 days a week Less than 3 days a week At least once a day

How often do you eat smoked food, food with high salt content, pickled food?*

Rarely or never 3-5 days a week Less than 3 days a week At least once a day

How often do you drink alcohol?*

Not at all Once/twice a week 3-4 times a week 5+ times a week

How often do you typically drink 2 or more Alcoholic drinks on 1 occasion?*

Once/twice a year/Never Monthly Weekly Daily

How often do you have someone to talk to when you feel lonely, depressed, angry or in need of help?*

Always Most of the time Sometimes Never

How often do you engage in physical activity for at least 20-30 minutes? E.g. a brisk walk, Swimming, aerobics, or exercise programme.*

More than 4 days a week 2-4 days a week Once a week Never

How often do you get 6-8 hours restful sleep?*

Always 5 times a week 2-4 times a week Rarely/Never

In the past 12 months, how often did you or your partner(s) use a condom when you had sex?*

Not applicable. I’m in a long-term monogamous relationship/ I’m not sexually active Always Sometimes Rarely/Never

Women only: How regularly do you go for a Pap Smear or breast examination?

Every 2-3 years Every 3-5 years Every 5-10 years Never

Men only: How regularly do you have a PSA test, or have your GP check your testis?

Once every 2-3 years Every 3-5 years Every 5-10 years Never

How often do you spend time in the sun without wearing sunscreen (of at least SPF 20)?*

Never, I always wear sunscreen Seldom, I wear sunscreen most of the time Often, I rarely wear sunscreen Whenever I’m in the sun, I never wear sunscreen

Do you have a family history of cancer? (Must be direct family members — father, mother, brother, sister, grandparents)*

None 1 family member 2-3 family members More than 4 close family members