Form

How did you hear about us?InternetWord of mouthOther

GoldWhite

Is this emergency contact same as Next of Kin: YesNo

How often do you have a drink containing alcohol?NeverMonthly or less2-4 times a month2-3 times 3 week4 or more times a week

IF Yes, How many standard drinks containing alcohol do you have on a typical day?
1 or 23 or 45 or 67 – 910 or more

How often do you have 6 or more drinks on one occasion?NeverLess than monthlyMonthlyWeeklyDaily or almost daily

Do you smoke cigarettes?YesNo

Planning to quit???YesNo

Have any of your close relatives had heart disease before 60 years of age ‘Heart Disease’ includes cardiovascular disease, heart attack, angina, and bypass surgery.YesNo

Have any of your close relatives had diabetes? ‘Diabetes | also known as type 2 diabetes or non-insulin dependent diabetes.YesNo

Do you have any close relatives who had melanoma?YesNo

Have any of your close relatives had bowel cancer before 55 years of age?YesNo

Do you have more than one relative on the same side of the family who had bowel cancer at any age?YesNo

Please think about your parents, children, brothers, sisters, grandparents, aunts, uncles, nieces, nephews, and grandchildren.

Have any of your relatives had prostate cancer before 60 years of age?YesNo

Have any of your close female relatives had ovarian cancer? YesNo

Have any of your close relatives had breast cancer before 50 years of ageYesNo

Do you have more than one relative on the same side of your family who has had breast cancer at any age?YesNo