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Women’s Health Risk Assessment

Women’s Health Risk Assessment
This questionnaire assesses your general cancer risk. Please answer all questions.
  • ExcellentGoodFairPoor
  • 0-1818-3940-6060/older
  • Never smoked2-3 times a weekI smoked a lot but I quit in the last yearEvery day
  • Never1-5 timesMore than 15 timesStill smoking
  • Never1-5 yearsMore than 5-10 yearsMore than 10 years
  • Normal weight>10kg overweight10-20kg overweight>20kg overweight
  • More than once a dayAt least once dailyAt least 4 times weeklyOnce or twice a week
  • Three or more cups a dayOne cup a day3-4 cups weeklyOnce or twice per week
  • Three or more cups per dayOne cup a day3-4 cups weeklyOnce or twice per week
  • Rarely or never3-5 days per weekLess than 3 days per weekAt least once a day
  • Rarely or never3-5 day per weekLess than 3 days per weekAt least once a day
  • Do not drink at all1-2 times per week3-4 times per week5 or more times per week
  • Once or twice per year/ neverMonthlyWeeklyDaily
  • NoLong time backRecentlyYes
  • More than 4 days per week2-4 days per weekOnce a weekNever
  • Not applicableLong time backRecentlyYes
  • NoLong time backRecentlyYes
  • MonthlyOccasionallyRarely or neverNo
  • Once every 2-3 yearsEvery 3-5 yearsRarelyNever
  • NoneMost of the timeRarelyNo
  • NoneOne family member was diagnosed2-3 family members were diagnosedMore than 4 family members were diagnosed

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