kno4no trest [gravityform id="2" title="false" description="false"] Risk Assessment DISCLAIMER*Please read and agree to the disclaimer below to proceed to the 10 following questions. The material provided in this questionnaire is intended for general information purposes only and should not be used or relied on for diagnostic or treatment purposes. While there is no guarantee that we can avoid cancer completely, our goal is to inform you of your risk so that you will be empowered to seek further information to maximize your chances of living a cancer-free life. The information is not intended to be patient education, does not create any physician-patient relationship, and should not be used as a substitute for professional diagnosis or treatment. If you reside in California, you are invited to request a consultation with Dr. Mel directly. Otherwise, please make sure to schedule a visit with your healthcare provider to discuss your results. Only then can a thorough risk assessment be conducted to determine the best health care for you. Yes, I have read, understood, and accept these terms. No, I do not wish to proceed ahead. 1. What is your biological gender?* Male Female 2. What is your current age?*<18 years old18 - 25 years old26 - 39 years old40 -49 years old50 - 54 years old55 - 59 years old60 - 64 years old65 - 69 years old70 - 74 years old75 - 79 years old80+ years old3. Type in your Body Mass Index (BMI)*Calculate your BMI using the calculator in the right margin. Note: Select the correct units of measure (imperial for Inches/pounds or metric for centimeters/kilograms)4. Have you ever had cancer?* Yes No, never What kind(s) did you have? (Check all that apply)* Breast Gynecologic Prostate Lung Colorectal Other gastrointestinal (see below for examples) Melanoma Non-melanoma skin cancer Sarcoma Brain (started in brain, didn’t spread to brain) Thyroid Adrenal, endocrine pancreas, or other hormonal Leukemia Lymphoma Not sure what type it was Other, not listed Please specify the kind of cancer you had.* Which type of Gynecological Cancer?*CervicalUterineOvarian or fallopian-tubeVulvar or vaginalDon’t knowHow old were you when you were first diagnosed?*<18 years old18 - 25 years old26 - 39 years old40 -49 years old50 - 54 years old55 - 59 years old60 - 64 years old65 - 69 years old70 - 74 years old75 - 79 years old80+ years old5. Have you ever had any of the following conditions? (Check all that apply)* Abnormal mammogram Abnormal pap smear Abnormal PSA (a blood tumor marker for prostate cancer) Abnormal prostate biopsy (that was not cancer) Colon polyp Barrett’s esophagus Abnormal mole None of the above 6. Have any of your family members had cancer?* Yes No, no one What kind(s) did they have? (Check all that apply)* Breast Gynecologic Prostate Lung Colorectal Other gastrointestinal (see below for examples) Melanoma Non-melanoma skin cancer Sarcoma Brain (started in brain, didn’t spread to brain) Thyroid Adrenal, endocrine pancreas, or other hormonal Leukemia Lymphoma Not sure what type it was Other, not listed Please specify the kind of cancer(s) they had.* Which type of Gynecological Cancer?*CervicalUterineOvarian or fallopian-tubeVulvar or vaginalDon’t know7. Have you ever been exposed to any of the following? (Check all that apply)* Tobacco smoke (eg. cigarettes, cigar, pipe smoking) Other forms of tobacco, such as chewing tobacco Second hand smoke Alcohol Sunburns Asbestos Radon Birth control pills Postmenopausal hormone replacement (HRT) Diethylstilbestrol (DES) Other hormones Immunosuppressive therapy Radiation therapy Other substance that I am concerned about None of the above On average, how many packs do/did you smoke per day (there are 20 cigarettes in a pack)?*How many years have you smoked for?*Are you still currently smoking?* Yes No How many years have you chewed tobacco for?*For how many years did you inhale second hand smoke?*On average, how many drinks do/did you consume per week?*Approximately how many sunburns have you had in your lifetime? (Enter a number e.g 4 or 5)*For how many years have you used birth control pills in total?How old were you when you received radiation therapy?< age 1010-1920-2526-30>30What areas of your body were radiated?For how many years have you used postmenopausal hormones in total?What types of immunosuppressive therapy have you received?Tell us about other substances that you have been exposed to that you are worried about?Other substance 8. How often do you exercise?* I don’t really 30-60 minutes 1-2 times per month 30-60 minutes 1-2 times per week 30-60 minutes 3-4 times per week 30-60 minutes 5+ times per week 9. Do you follow a special diet?* Yes Unrestricted What kind? (Check all that apply)* Vegan Vegetarian (strictly plant-based, but not vegan) Lacto-ovo (fruits & vegetables plus eggs and/or dairy) Pescetarian (fruits & vegetables plus fish and/or eggs/dairy) Gluten-free Kosher Other, please specify: Please specify:* 10. Please rate your stress level from 1-5* 5 - I am always stressed out 4 - I get stressed easily 3 - My stress levels varies widely 2 - I am usually relaxed 1 - I am always zen! How can we reach you about your results?Name* First Last Please confirm the best way to reach you about your results NOTE: Your information will be treated with confidentiality and will not be shared with third parties. Email* Please confirm your emailPhone*please provide us your phone numberThank you for your time. We respect your decision to not agree to our disclaimer, but we are afraid that we cannot allow you to proceed without doing so.
