CAP Movement Survey
To collate data of cancer patients for study and research purpose to find the etiology and to fight the root cause.
Also will try to mobilize financial help for those who are needy.
www.snehahriday.org
Cancer Awareness & Prevention Survey
1. Full Name *
Your answer
2. Age *
Your answer
3. Gender *
4. Occupation
Your answer
5. Address/Place/District *
Your answer
6. State *
Your answer
7. Contact Number *
Your answer
8. Diagnosed Date
MM
/
DD
/
YYYY
9. Type of Cancer
Your answer
10. Stage
Your answer
11. Treatment
12. Family history of cancer
13. Details of breast feeding (applicable only for female breast cancer patients)
14. Any other illness
15. Any chronic wounds
16. Addiction
17. Vegetarian
18. Hotel food consumption
19. Maida based food consumption (bread, porotta, bakery items etc)
20. Junk food consumption (Pepsi/cola, Burger/Pizza etc)
21. Beef Consumption
22. Chicken Consumption
23. Fish Consumption
24. Other Non-Veg Consumption
25. Dinner timing
26. Breakfast/Lunch/Dinner
27. Oil using at home
28. Physical Activity/Exercise
29. Are you looking for any financial support
30. Any comments or what you think the cause of your disease
Your answer
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