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Women’s Health Risk Assessment

This questionnaire assesses your general cancer risk. Please answer all questions.

Would you say your health in general is*
Excellent Good Fair Poor
What is your age currently*
0-18 18-39 40-60 60/older
Do you currently smoke cigarettes, cigars, pipes, snuff or hookah?*
Never smoked 2-3 times a week I smoked a lot but I quit in the last year Every day
If ever used, how much / frequently do you use tobacco (cigarettes per day)?*
Never 1-5 times More than 15 times Still smoking
How long have you/ did you use tobacco/cigarettes?*
Never 1-5 years More than 5-10 years More than 10 years
What is your weight currently?*
Normal weight >10kg overweight 10-20kg overweight >20kg overweight
How frequently do you include high fibre food in your diet? (Whole grain food whole grain cereals, beans and legumes)*
More than once a day At least once daily At least 4 times weekly Once or twice a week
About how many cups of fruit do you eat each day? (One cup of fruit = one small fruit, one cup of 100% fruit juice or ½ cup dried fruit)*
Three or more cups a day One cup a day 3-4 cups weekly Once or twice per week
About how many cups of vegetables do you eat each day? ( One cup of vegetables = one cup of raw or cooked vegetables, 1 cup of 100 % vegetable juice, or 2 cups of raw leafy greens)*
Three or more cups per day One cup a day 3-4 cups weekly Once or twice per week
How often do you eat high-fat foods? (e.g. fried foods, fatty meats, packaged foods high in fats, snacks, added fat like oil)*
Rarely or never 3-5 days per week Less than 3 days per week At least once a day
How often do you eat smoked food, food with high salt content, pickled food?*
Rarely or never 3-5 day per week Less than 3 days per week At least once a day
How often do you take alcoholic beverages?*
Do not drink at all 1-2 times per week 3-4 times per week 5 or more times per week
How often do you typically drink 2 or more alcoholic drinks on one occasion?*
Once or twice per year/ never Monthly Weekly Daily
Have you previously had non- cancerous breast lumps?*
No Long time back Recently Yes
How often do you engage in physical activity to raise your heart rate? (e.g. brisk walk, swimming, aerobics, exercise programme for at least 20 – 30 min)*
More than 4 days per week 2-4 days per week Once a week Never
Do you have children, if yes did you, or are you currently breastfeeding?*
Not applicable Long time back Recently Yes
Are you currently on birth control or hormone replacement therapy*
No Long time back Recently Yes
Do you do breast self-examination monthly*
Monthly Occasionally Rarely or never No
When did you last go for a pap smear?*
Once every 2-3 years Every 3-5 years Rarely Never
How much time do you spend in the sun without sunscreen SPF 20 or more protection?*
None Most of the time Rarely No
Do you have a family history of cancer? (Must be direct family members – father, mother, brother, sister, grandparents) Age/s when diagnosed*
None One family member was diagnosed 2-3 family members were diagnosed More than 4 family members were diagnosed

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0800 22 6622 Toll Free
072 197 9305 English and Afrikaans (text only)
071 867 3530 isiXhosa, isiZulu, Sesotho, Setswana and Sepedi (text only)

info@cansa.org.za

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