Oral Cancer Screening Questionnaire
Personal Information
Full Name
Age
Gender
Male
Female
Other
Medical & Lifestyle History
Do you smoke tobacco?
Yes
No
Do you use smokeless tobacco (chewing, snuff)?
Yes
No
Do you consume alcohol?
Yes
No
Any family history of oral cancer?
Yes
No
Symptoms
Have you noticed any of the following?
Sore in the mouth that doesn't heal
Lump or thickening in the cheek
Unexplained bleeding in the mouth
Numbness of tongue or mouth
Persistent pain in mouth/throat
Other
Comments
Additional Information