English and Spanish versions are available: Dietary Screener in English [PDF - 142 KB] When diagnosed? Cancer cells develop a degree of autonomy from external regulatory signals that are responsible for normal cellular homeostasis. Chemotherapy decreases the number of infection-fighting white blood cells in your body. When were you diagnosed and at what age? The survey contains questions about whether you recommend or administer various procedures, your views on whether you or your area’s health care system can accommodate an increased screening volume, and some general questions about your medical practice. Symptoms Matter (YSM): Prostate Cancer questionnaire. Breast Cancer Research Questionnaire A breast cancer research questionnaire is needed to undertake the background data check of a person diagnosed with breast cancer. Did you have a support network? About the reviewed questionnaires: The questionnaires share the following characteristics. What stage were you diagnosed with? Cancer Family History Questionnaire NAME_____ DOB:_____ Have you ever been diagnosed with cancer? Have you been tested for COVID … (i.e. Cancer cells can easily be destroyed by radiations due to a) fast mutation b) rapid cell division c) lack of mutation d) lack of oxygen 4. What type of cancer are/ have you been affected by? The questionnaire will help yield . 4 Physical Activity Questionnaire 10. If the item is not applicable, please select N/A. Subsequent mutations lead to malignant tumour which break through the basal membrane and spread to distant locations. CANCER— LEUKEMIA QUESTIONNAIRE (6) Has there been any evidence of recurrence or relapse of the leukemia or related illness? Don't be afraid to ask questions about prostate cancer, no matter how minor they may seem. It provides life assurance and pensions. Development of a European Organization for Research and Treatment of Cancer questionnaire module to assess the quality of life of ovarian cancer patients in clinical trials: a progress report. Type(s) of Cancer Age(s) at Diagnosis Current Age You Immediate Family Total Number Number with Cancer Type(s) of Cancer Age(s) at Diagnosis Current Age Age at Death Your Daughter(s) Your Son(s) Your Brother(s) Your Sister(s) PATERNAL RELATIVES Type(s) of Cancer Age(s) at Diagnosis Current … 1-800-477-9774 Maryland Cancer Hotline (toll free) Over Breast Cancer Survivor – Interview Questions 1. The questions can be used at study entry and during follow-up. Multiple mutations lead to a tumour mass. 2. Have you worried about cancer in the last week? Development of the Lymphoedema Genito-Urinary Cancer Questionnaire They are: • Designed to address covariates (confounding) exposures, not main variables or the principal subject of a study, which might require more detailed questions Cancer Personal and Family History Questionnaire Your doctor referred you to the Mackenzie Health Genetics clinic because of a personal or family history of cancer. Hereditary Cancer Questionnaire Personal Information Patient Name: _____ Date of Birth: _____ Today’s Date: _____ Gender (M/F): ____ Healthcare Provider: _____ Age: _____ Reason for Visit: _____ Instructions: This is a screening tool for cancers that run in families. If you do not know the answer, please select D/K. Tobacco Use Questionnaire (C-TUQ) C-TUQ asks cancer patients and survivors about their tobacco use. Download Active Smoking Questionnaire (Word, 27 KB). The Cancer Patient. WE CAN HELP! Biopsychosocial model of breast cancer specific of life questionnaire modules, and methodological exposition. It’s also important to know which side of your family the relative is on. Please mark (Y) for those that apply to YOU and/or YOUR FAMILY. Cancer is caused by a) uncontrolled mitosis b) uncontrolled meiosis c) rupturing of cells d) loss of immunity of the cells 3. It's important for you to have open discussions with your cancer care team. lung cancer is to STOP SMOKING. What kind of treatment and last date of treatment, if fully recovered (including surgery, radiation or chemotherapy? What stage of cancer, 1-4? How was the cancer initially detected? Anyone can get cancer, although the risk goes up with age. Please complete this questionnaire to the best of your abilities and return it to your physician. Yes No D/K 2. cancer early when it is the most easily treated. Download Breast Cancer Specific Quality Of Life Questionnaire doc. Cancer Risk Assessment Questionnaire _____ _____/_____/_____ _____/_____/_____ Patient Name Date of Birth Date Completed This is a screening tool for the common features of hereditary cancer. Cancer Screening Questionnaire Family Cancer History When it comes to cancer, knowing your family history is important. Multiple Choice Questions on Cancer 1. 1. Who gets cancer? Risk Assessment Questionnaire If you are receiving chemotherapy, you may be at risk for getting an infection when your white blood cell count is at its lowest point. If you have not registered for MyChart™, ask a member of your healthcare team about it. Cancer cells are a) BHK b) Veo c) HL-8 d) Hela cells 2. Conducted by: In collaboration with: Public reporting burden for this response is estimated to be an average of 20 minutes per questionnaire including time for reviewing instructions. PDF | • Purpose: The EORTC Quality of Life Study Group has developed the questionnaire module for lung cancer QLQ-LC13. Your family history is an important tool to help determine why cancers are occurring in a family. Self-Administered Questionnaire: Web; Interviewer-Administered Questionnaire. Fill out the chart below with as much detail as you can. 2. The Dietary Questionnaire for Epidemiological Studies (DQES v3.2) is a modification of the food frequency questionnaire that was developed by Cancer Council Victoria in the late 1980s to measure the dietary intake of people taking part in the Melbourne Collaborative Cohort Study. Life Insurance Health Screening Questionnaire Client Name: _____ Agent Name: _____ Proposed Death Benefit Amount: _____ ... Cancer 1. 6. Where cancer originated? The firm is on the Financial Services Register, registration number 117672. Our service will allow us to give you the most technologically advanced screening possible to increase the chances of cancer detection and early intervention to optimize your health. You can complete YSM the night before or the morning of your appointment on your computer or mobile device. 2. diagnostic follow-up, and surveillance for colorectal cancer. The survey assesses the impacts of cancer therapy in four domains: physical, social/family, emotional, and functional. 4. Endogenous insulin functions in the body in which of the following ways: a. Endocrine action only b. Mitogenic action only c. A and B . This questionnaire can be analysed to suggest the best treatment for the patient and help in stopping the disease lineage. 5. Lung Cancer Screening Clinic Intake Questionnaire DDouglas Arenberg, M.D.ouglas Arenberg, M.D. Here are 10 common—and important—questions people often think about. Breast & Cervical Cancer Screening Questionnaire If you need help paying for screening or want more information, please call to learn about programs that could help you get screened! r No r Yes Details: _____ _____ (7) Has the proposed insured’s spleen been removed as part of the t reatment procedure? How did you feel when you first received the news? r No r Yes Details: _____ _____ (8) Has there ever been any kind of other cancer diagnosed for the proposed insured? 3. The Dietary Screener Questionnaire (DSQ) was administered by interviewers in the National Health and Nutrition Examination Survey (NHANES) 2009-2010 series. When it comes to cancer, sometimes the simplest questions go unasked. 1. Cancer Coping Questionnaire (21-item version) Name..... Hospital number..... People have many ways of coping with the stress that cancer puts them under. Find out all you can about your whole family. 1. # ˇ & ˇ 3% ˜˙ ˇ ˚˚˚ 3=˚ <˛˚˙ ˝˘ ˙ ˇ˜ "* !ˆˇ * ˆ˙ˇ ˙˙$ + "7 49 3>< = 1 ˘ˇ˚˛˚˙ ˝˘ ˙ ˇ˜ "* ! The FACT-G is the original questionnaire that led to the development of the larger Functional Assessment of Chronic Illness Therapy (FACIT) collection of quality of life instruments. CANCER— BREAST CANCER QUESTIONNAIRE (7) Has there been any evidence of recurrence? On the following pages there is a list of different methods of coping. through a BSE, a CBE or an annual mammogram) 4. How stressful has the last week been for you? 4 being metastasis and uninsurable. Physicians’ Cancer Screening Recommendations and Practices Breast and Cervical Cancer Screening Questionnaire . Malignancies associated with type 2 diabetes include which of the following? (Select all that apply) Breast Lung, Trachea & Bronchus Prostate Colorectal (Bowel cancer) Melanoma Non-Hodgkin lymphoma Head & Neck Bladder Kidney Uterus Cervical no signs or symptoms of cancer Other I have finished treatment but my cancer is still present Don’t know 11. PSA for prostate cancer <1? Multiple Choice Assessment Questions . 37 Full PDFs related to this paper Breast Cancer Awareness Survey Questionnaire: Note: BCA means Breast Check-up Application Rate the following by ticking either one of the options for each of the questions 0=Strongly disagree 1=Disagree 2=Neither agree nor disagree 3=Agree 4=Strongly agree Performance Expectancy 1. 5. COVID-19: IMPACT OF THE PANDEMIC AND HRQOL IN CANCER PATIENTS AND SURVIVORS I. COVID-19 EXPERIENCES Please answer the questions below to the best of your knowledge. Eur J Cancer. To your knowledge, have you been exposed to someone with COVID-19? a. Lung cancer begins when abnormal cells in the lung grow out of control. Tumour / cancer questionnaire page 8 of 8 / The Royal London Mutual Insurance Society Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. 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