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).

Your Background

About You

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

Residential Address

Health History

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

Colonoscopy i

Have you ever been vaccinated for HPV?

Mammogram/Breast MRI i

PAP Smear i

Tested positive for HPV

Prostate Exam i

Smoking History

Cigarette Use

Have you ever smoked cigarettes?

Have you smoked roughly 100 cigarettes in your entire life?

Do you currently smoke cigarettes?