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

What is your race? Mark all that apply.

Can you specify which Native American tribe you belong to? Mark all that applys.

Do you consider yourself to be any of the following? Mark all that apply.

Family History

Can you answer questions about your blood (NATURAL) relatives?

Did any of your NATURAL RELATIVES (parents, brothers and sisters) have any of the following conditions?

Mark all that apply.

Screening and Medical History

Please tell us how long it has been since you last had the following medical examinations:

General physical or “checkup"

Colonoscopy i

Women's Health

Please tell us how long it has been since you last had the following medical examinations:

Mammogram/Breast MRI i

Clinical Breast Exam i

PAP Smear i

Tested positive for HPV

Men's Health

Please tell us how long it has been since you last had the following medical examinations:

Digital Rectal Exam i

PSA (Prostate Specific Antigen) Blood Test i

Smoking History

Have you smoked roughly 100 cigarettes in your entire life?

Do you currently smoke cigarettes?


Smoking & Tobacco Use History

cigarettes usage

Have you ever smoked cigarettes?

Are you currently smoking cigarettes regularly?

pipe usage

Have you ever smoked a pipe?

Are you currently smoking pipes regularly?

cigar usage

Have you ever smoked a cigar?

Are you currently smoking cigars regularly?

chewing tobacco usage

Have you ever used chewing tobacco?

Are you currently using chewing tobacco regularly?

snuff usage

Have you ever used snuff?

Are you currently using snuff regularly?

e-cigarette usage

Have you ever smoked an e-cigarette?

Are you currently smoking e-cigarettes regularly?

hookah usage

Have you ever smoked a hookah?

Are you currently smoking hookahs regularly?

Alcohol Consumption

For the following questions we are interested in your consumption of three major types of beverages: beer, wine, and distilled liquor.

  • Beer: All, including malt beverages, but not non-alcoholic beer
  • Wine: All wines, including sherry, port, fruit wines, and wine coolers
  • Liquor: All distilled beverages (gin, whiskey, cognac), mixed drinks, cocktails, and liquor with more than 20% alcohol

One drink = 1.5 oz. shot of liquor, 4 oz. glass of wine, or 12 oz. can/bottle of beer

Over the last year. What are your drinking habits?

Physical Activity

On average how many hours/minutes in a week do you spend on the following activities?

We are interested in the intensity at which activities are being performed or the magnitude of effort required to perform an activity or exercise that gets your body moving. It can be thought of as “How hard a person works to do the activity.”

Light Activity: such as casual walking, light bicycling under 5 mph, stretching, dancing slowly, standing and light work (cooking, washing dishes), leisurely sports (table tennis, playing catch), light yard/house work.
“This activity level does not get your heart rate up. At this level you could sing during the activity.”

Moderate Activity: such as walking at a moderate or brisk pace (3-5 mph), hiking, bicycling 5-9 mph, low-impact aerobics, swimming, housework that involves scrubbing/cleaning, moderate yard work, tennis, volleyball, carrying a child >50lbs, occupations that require extended standing, lifting objects under 50lbs, pushing/pulling objects.
“This activity level raises your heart rate and breaks a sweat. You can still talk but can’t sing the words to a song.”

Vigorous Activity: (such as race walking, jogging/running, high impact/step aerobics, jumping rope, circuit training, competitive sports, occupations that require periods of running, heavy lifting or rapid movement).
“At this activity level you won’t be able to say more than a few words without taking a breath

Your Diet

Please check the options that best describe your eating habits over the last year.

Skip breakfast?

Eat 4 or more meals from sit-down or takeout restaurants per week?

Eat less than 3 servings of whole-grain products a day?
Serving = 1 slice of 100% whole-grain bread; 1 cup whole-grain cereal; high-fiber cereal, oatmeal; 3-4 whole-grain crackers; ½ cup brown rice or whole-wheat pasta

How many servings of fruit do you eat a day.
Serving = 1/2 cup or 1 med. fruit or 4oz. 100% fruit juice

How many servings of vegetables/potatoes do you eat a day.
Serving = 1/2 cup vegetables/potatoes, or 1 cup leafy raw vegetables

Eat or drink less than 2-3 servings of milk, yogurt, or cheese a day?
Serving = 1 cup milk or yogurt; 1.5 - 2 ounces cheese

Use 2% (reduced fat) or whole milk instead of skim (non-fat) or 1% (low-fat) milk?

Use regular cheese (like American, cheddar, Swiss, Monterey Jack) instead of low-fat, part skim cheeses as a snack, on sandwiches, pizza, etc.?

In an average week how often do you:

Eat beef, pork, or dark meat chicken more than 2 times a week?

Eat more than 6 ounces (see sizes below) of meat, chicken, turkey or fish per day?
Note: 3 ounces of meat or chicken is the size of a deck of cards or ONE of the following: 1 regular hamburger, 1 chicken breast or leg (thigh & drumstick), or 1 pork chop.

Choose higher-fat red meats like prime rib, T-bone steak, hamburger, ribs, etc., instead of lean red meats?

Eat the skin on chicken and turkey and the fat on meat?

Use processed meats (like bologna, salami, corned beef, hot dogs, sausage or bacon) instead of low-fat processed meats (like roast beef, turkey, lean ham; low-fat cold cuts/hotdogs)?

Eat fried foods such as fried chicken, fried fish or french fries?

Eat regular potato chips, nacho chips, corn chips, crackers, regular popcorn, nuts instead of pretzels, low-fat chips or low-fat crackers, air-popped popcorn?

Use regular salad dressing and mayonnaise instead of low-fat or fat-free salad dressing and mayonnaise?

Add butter, margarine or oil to bread, potatoes, rice or vegetables at the table?

Cook with oil, butter or margarine instead of using non-stick sprays like Pam or cooking without fat?

Eat regular sweets like cake, cookies, pastries, donuts, muffins, and chocolate instead of low-fat or fat-free sweets?

Eat regular ice cream instead of sherbet, sorbet, low-fat or fat-free ice cream, frozen yogurt, etc.?

Eat sweets like cake, cookies, pastries, donuts, muffins, chocolate and candies more than 2 times per day?

Drink 16 ounces or more of non-diet soda, fruit drink/punch a day?
Note: 1 can of soda = 12 ounces

Eat high-sodium processed foods like canned soup or pasta, frozen/packaged meals (TV dinners, etc.), chips?

Add salt to foods during cooking or at the table?