Cancer Screening and Prevention Questionnaire

Cancer screening is simply too important to let slide. Screening tests help detect cancer long before symptoms appear, and the cancers found through routine screening are generally smaller and at an early stage when treatment is most effective.

When you submit this form, you will be provided with an email summarizing the recommendations for cancer screenings and health behaviors. If you have additional questions, call Roswell Park toll-free at
1-800-ROSWELL (1-800-767-9355).

Fields marked with an asterisk * are required.

Your Background

About You

What is your birth sex? *
What is your race or ethnicity? Mark all that apply.
Can you specify which Native American or First Nations tribe you belong to? Mark all that apply.
Do you consider yourself to be any of the following? Mark all that apply.

Contact Methods

Health History

Do you currently have, or have you ever had any of the following types of cancer? Mark all that apply.

How long it has been since you last had the following medical examinations?

Colonoscopy An examination of the inside of the colon using a colonoscope inserted into the rectum. Samples of tissues may be collected.
Have you ever been vaccinated for HPV?
Mammogram/Breast MRI Imaging and x-ray tests of each breast to look for cancer.
PAP Smear Also called a Pap test, a small sample of cells from inside and outside the cervix (the lower part of the uterus) is collected using a cotton swab or a small brush or spatula. The cells are examined for any abnormalities.
Tested positive for HPV
Prostate Exam Insertion of a gloved, lubricated finger into the rectum to feel for any abnormalities.

Smoking History

Cigarette Use

Have you ever smoked cigarettes?
Have you smoked roughly 100 cigarettes in your entire life?
Do you currently smoke cigarettes?
Years
Age