Oral Cancer Risk Assessment Input Form

,      Exam Date: Name: Date of Birth: Internal Patient ID: Previser Patient ID:

Patient Cancer History   Family Cancer History   Race   Breast   Skin Colon or Rectum   Urinary Bladder Lung and Bronchus   Uterine Oral Cavity   Other Prostate         Breast   Skin Colon or Rectum   Urinary Bladder Lung and Bronchus   Uterine Oral Cavity   Other Prostate         a) White non-Hispanic b) White Hispanic c) Black d) Chinese e) Filipino f) Hawaiian g) Japanese h) Korean i) Vietnamese j) Other

Cigarette Use   a) Never used b) Former smoker c) < 10 per day d) > = 10 per day Age Began Smoking Cigarettes Year Quit   Cigar/Pipe Use   a) Never used b) Former smoker c) <1 per day d) 1-2 per day e) >2 per day Age Began Smoking Cigars/Pipe Year Quit   Smokeless Tobacco Use   a) Never used b) Former user c) Occasional user d) Daily user Age Began Using Smokeless Tobacco Year Quit   Alcohol Use a) None b) < = 3 servings per week c) 4-6 servings per week d) 1 serving per day e) > =2 servings per day   Oral Cancer Examination   a) Clinical examination will be done later in the appointment b) No lesions were visualized during the examination c) Lesions were visualized during the examination   Visualized Lesions (check all that apply)   White lesion   Swelling Red lesion   Tissue Enlargement Red-white lesion   Induration (tissue hardness) Ulcer   Non-odontogenic radiolucency