Professional Documents
Culture Documents
Name
Gender- □ Male □ Female
Age
6. Do you have patches on lining of the mouth/tongue, usually red or red and white in color?
□ Yes □ No
7. Is there any lump or thickening of the skin or lining of the mouth? □ Yes □ No
8. Has your swelling persisted for over 3 weeks? □ Yes □ No
9. Do you have ulcers or sores that do not heal? □ Yes □ No
10. Are there any loose teeth with no clear reason? □ Yes □ No
11. Is there any pain when swallowing? □ Yes □ No
12. Is there a sensation that something is stuck in the throat? □ Yes □ No
13. Do you have hoarse voice? □ Yes □ No
14. Do you feel any pain in the neck or ear that does not go away? □ Yes □ No
20. Have you ever had radiation therapy to the chest for treatment of a disease? □ Yes □ No
21. Have you ever been tested and found to have a gene mutation linked to breast cancer?
□ Yes □ No
22. Do / did you ever use oral contraceptive pills (OCP)?
- No
- Yes, I am currently taking OCP
- Yes, I have used OCP in the past but not taking now
If yes, for how many years have you used the OC pills? ..........................................................
23. Have you gone through menopause (stopped having menstrual periods for at least past 12
months)? □ Yes □ No
If yes, was it-
- Before age 55
- 55 or later