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Risk Assessment Form
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Enter Your Full Name *
Please enter your email-id *
Please enter your phone number *
Gender *
Age *
Have you had genetic testing for Cancer? *
Has anybody in your family had cancer? *
If yes, what type of cancer
Did you drink alcohol in the past? *
If yes, please mention the duration *
Have you had the habit of smoking or chewing tobacco/ do you still do it? *
If yes, please mention the duration. *
Where do you live? *
What is the level of greenery around your house? *
How frequently are you exposed to sunlight or tanning beds ? *
If yes, please mention the duration per session
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How often do you have Flu symptoms? *
How long do the symptoms last?
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Do you have the history of any of the following? Chronic diseases (COPD, Type 2 Diabetes, CVD) *
How old were you when you had your first X-ray/ CT Scan/ PET Scan or any other exposure to radiation? *
If yes, how long ago?
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Have you got yourself vaccinated against HPV (Gardasil), Hepatitis-B or any other type of cancer? *
If yes, mention the type or name of the vaccine
Have you ever been diagnosed with any other type of cancer?
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