CONFIDENTIAL 保密

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CONFIDENTIAL 保密



RISK ASSESSMENT / EARLY DETECTION QUESTIONNAIRE 風險評估 / 預早偵測 問卷



Please complete this questionnaire truthfully and to the best of your ability. This will help your doctor to evaluate your cancer risk and early detection of cancer.

請盡閣下所知而據實填寫此問卷, 此有助醫生評估閣下之癌症風險及預早偵測癌病 ە

Name 姓名 _____________________________________ Sex 性別 __________________________

Date of Birth 出生日期 (d日/m月/y年) ___________________________ Age 年齡 _____________

HKID No. 身份證號碼 ________________________________________________________________

Telephone No. 電話號碼____________________ Fax No. 傳真號碼 _________________________

Home Address 住址 __________________________________________________________________ __________________________________________________________________

Name and telephone no. of spouse or next of kin (for doctor’s record) 配偶或近親家屬的姓名及電話號碼 (醫生需作記錄)

Name 姓名 _______________________________ Telephone No. 電話號碼 __________________________

Name and telephone no. of family doctor 家庭醫生的姓名及電話號碼



Name 姓名 _______________________________ Telephone No. 電話號碼 __________________________


Ethnicity 種族



□ Asian 亞洲人

□ Black or African-American

□ American Indian/Alaskan Native □ Native Hawaiian or Pacific Islander □ White 白種人

□ Hispanic/Latino 西班牙人/拉丁美洲人 □ Jewish 猶太人

Your Height and Weight 閣下的身高及體重



1. What is your height (in feets/inches)? 你的身高 (尺/寸)?

_______________

2. What is your weight (in pounds)? 你的體重 (磅)?

_______________

3. How much did you weight when you was new born (in pounds)? 你出生時候的體重 (磅)?

_______________

4. How much did you weight at age 18 (in pounds)? 你十八歲時候的體重 (磅)?

_______________

Your Family History 閣下的家族史



1. Has any member of your immediate family (parents, grandparents, uncles and aunties,

brothers and sisters, children, first degree cousin) ever been diagnosed with cancer? 閣下之直系家屬(父母, 祖父母, 叔嬸, 兄弟姊妹, 子女, 近親表兄弟表姊妹) 曾否診斷為患癌病?



□ Yes是 □ No否 □ I don’t know我不知道

If yes, please list: 若是, 請列於下表:

Family member 親屬 Type of cancer 癌病種類 Age at diagnosis 確診時年齡 1. 2. 3.

2. Do you have a BRCA1 or BRCA2 gene mutation?

閣下是否有BRCA1 或 BRCA2 基因突變?

□ Yes是 □ No否 □ I don’t know我不知道




Previous Diagnosis 過往診斷



1. Have you ever had any type of cancer except for non-melanoma skin cancer?

閣下是否曾患任何癌病 (良性皮膚瘤除外)?

□ Yes是 □ No否

If yes, what kind and when did that occur?

若是, 何種癌症及在何時發生? _________________________________

Your Medical History 閣下的病歷



1. Your blood type A, A+ or A-?

閣下之血型是否 A, A+ 或 A-?

□ Yes是 □ No否

2. Have you ever had benign breast disease? Benign breast disease is a large group of noncancerous

conditions of the breast that includes cysts, fibroadenomas, and hyperplasia?

閣下是否曾患有良性乳房疾病？良性乳房疾病是一種非癌性的乳房病變，當中包括囊腫，纖維腺瘤，乳腺增生？



□ Yes是 □ No否

3. Have you taken either Tamoxifen or Raloxifene for 5 years or more?

閣下是否曾服用 “他莫昔芬” 或 “雷洛昔芬” 並持續五年或以上？

□ Yes是 □ No否

4. Have you had a Pap test within the last 3 years? 閣下在過去3年內是否曾接受柏氏抺片檢查?



□ Yes是 □ No否

5. An abnormal pap smear? 柏氏抺片檢查有沒有異常?

□ Yes是 □ No否

6. Have you ever had a hysterectomy?

閣下是否曾進行子宮切除手術？



□ Yes是 □ No否


7. Have you ever been told by a doctor that you had an H Pylori infection?

有沒有醫生曾經告訴你是有幽門螺旋桿菌？



□ Yes是 □ No否 □ I don’t know 不知道

8. If yes, were you treated for the H Pylori infection?

如有，有沒有接受治療？

□ Yes是 □ No否 □ I don’t know 不知道

9. Have you had chronic inflammatory bowel disease for 10 or more years? This includes Crohn's disease and ulcerative colitis.

閣下是否有慢性/長期的腸道炎症，並持續十年或以上？這包括孔羅氏症(消化道瘜肉)及潰瘍性結腸炎。



□ Yes是 □ No否

Your Screening History 閣下的身體檢查歷史

1. Within the last 10 years, have you had a colonoscopy?

過去十年內，是否曾接受過大腸鏡檢查？

□ Yes是 □ No否 □ I don’t know 不知道

2. Within the last 5 years, have you had a flexible sigmoidoscopy (flex sig), double contrast barium

enema, stool DNA test, or virtual colonoscopy?

過去五年內，是否曾接受過軟式乙狀結腸鏡檢查，結腸鋇劑灌注雙重對比X光攝影檢查，大

便基因測試或虛擬大腸鏡檢查？

□ Yes是 □ No否 □ I don’t know 不知道

3. Within the last year, have you had a fecal occult blood test (FOBT) or a fecal immunochemical test

(FIT)?

過去一年內，是否曾接受過大便隱血測試或大便免疫化學測試？

□ Yes是 □ No否 □ I don’t know 不知道

Your Physical Activity 閣下的體能活動



1. Do you walk (or do other moderate activity) for at least 30 minutes on most days, or at least 3 hours

per week?

你每日有沒有步行或做其他適度的運動至少30分鐘, 或每星期至少3少時?

□ Yes是 □ No否


Your Environment 閣下的生活環境

1. Have you lived in or near a large city for at least 10 years of your life?

閣下是否曾在大城市生活至少10年?

□ Yes是 □ No否

2. Have you ever worked with asbestos without adequate protection? Adequate protection includes

respirators, eye protection, gloves and boots.

閣下是否曾經於工作中接觸石棉而且沒有足夠的保護? 足夠的保護包括口罩，眼罩，手套及

靴。

□ Yes是 □ No否

3. What's the total amount of time you worked with asbestos without protection?

閣下合共有多少時間在工作中接觸石棉而且沒有足夠的保護?

□ Less than 5 years 少於五年

□ Between 5 and 20 years 五至二十年 □ More than 20 years 多於二十年

4. Have you ever worked with any of these chemicals without adequate protection? 閣下是否曾經於工作中接觸以下化學品且沒有足夠的保護?

 Radon 氡氣 □ Yes是 □ No否  Cadmium 鎘 □ Yes是 □ No否  Chromium 鉻 □ Yes是 □ No否  Beryllium 鈹 □ Yes是 □ No否  Aluminum 鋁 □ Yes是 □ No否  Silica 硅土 □ Yes是 □ No否  Sulfuric acid mist 硫酸 □ Yes是 □ No否  Bis(chloromethyl) ether and chloromethyl ether □ Yes是 □ No否  Coke 焦炭 □ Yes是 □ No否  Mustard gas 芥氣 □ Yes是 □ No否

5. What's the total amount of time you worked with the chemical(s) without protection? 閣下合共有多少時間在工作中接觸以上化學品而且沒有足夠的保護?

□ Less than 5 years 少於五年

□ Between 5 and 20 years 五至二十年 □ More than 20 years 多於二十年

6. Have you ever been involved with any of the following processes without adequate protection? 你是否曾經接觸以下情況而且沒有足夠的保護?

 Arsenic smelting 熔煉砷 □ Yes是 □ No否  Coal gasification 氣化煤炭 □ Yes是 □ No否  Iron or steel founding 提煉鋼鐵 □ Yes是 □ No否


7. How long were you involved with the process(es) without protection? 閣下有多少時間接觸以上情況而且沒有足夠的保護?

□ Less than 5 years 少於五年

□ Between 5 and 20 years 五至二十年 □ More than 20 years 多於二十年

Your Smoking History 閣下的吸煙歷史

1. Do you smoke cigarettes? 閣下是否吸煙?

□ Never 從不

□ Yes是

□ I used to smoke but I quit 曾經但已戒煙

2. How many cigarettes do you smoke per day?

閣下每天吸煙的數目？

□ 14 or fewer cigarettes a day 每天少於十四根

□ between 15 and 25 cigarettes a day 每天十五至二十五根 □ more than 25 cigarettes a day 每天多於二十五根

3. If you have quit smoking, please state quantity and duration of smoking history:

________piece per day for ________years, quit date _______/_______/______ 若你已戒煙, 請述過往吸煙量及歷程

每日______根, 吸煙 _______年, 戒煙日期 _______/_______/_______

4. Do you smoke cigar? 你是否吸雪茄?

□ Never 從不 □ Yes是 □ I used to smoke but I quit 曾經但已戒吸雪茄



If yes, how many per day? 若是, 每日多少根? 每日______根per day

Your Diet 閣下的飲食習慣



1. Do you eat 3 or more servings of red meat a week? 1 serving is 4 ounces - about the size of a deck of

cards

閣下每星期是否會進食3份或以上的紅肉? (1份紅肉等於4安士)



□ Yes是 □ No否



2. How many servings of milk or dairy products do you have on most days? One serving is a cup of

milk, a cup of yogurt or about 1 ½ oz of cheese.

你每日會進食多少份牛奶或乳製產品？ 一份相等於一杯牛奶、一杯乳酪或半安士芝士。

□ Less than 1 少於一份 □ 1 – 2 一至兩份

□ 3 or more 三份或以上

3. Do you eat 5 or more servings of fruit and vegetables per day? A serving is one medium apple,


banana or orange, 1 cup of raw leafy vegetable (like spinach or lettuce), ½ cup of cooked beans or peas, ½ cup of chopped, cooked or canned fruit/vegetable or ¾ cup of fruit/vegetable juice.

閣下每日是否進食五份或以上的蔬菜及水果? 一份相等於一個中蘋果、一條香蕉或一個橙，一杯新鮮

不經煮熟的綠葉蔬菜(如菠菜或萵苣)、半杯經煮熟豆或豌豆、半杯切碎煮熟的罐頭蔬菜或水果或3/4杯果汁或蔬菜汁。

□ Yes是 □ No否



4. Do you eat 5 or more servings of food with animal fat a day? These foods include red meat and dairy

products like cheese. 1 serving is a small amount - enough to fit in the palm of your hand.

閣下每日是否進食五份或以上含有動物脂肪的食物? 這些食物包括紅肉和乳製品如芝士，1 份等於



□ Yes是 □ No否



5. Do you eat 5 or more servings of tomato-based foods a week? These foods include spaghetti sauce

and salsa. 1 serving is about ½ cup of sauce.

閣下每星期是否進食五份或以上含有蕃茄的食物? (這些食物包括意粉醬及XX，而一份相等於半杯蕃

茄醬)



□ Yes是 □ No否



6. How many times a day do you eat canned foods, process foods (like potato chips), preserved meats

(like bacon), or frozen meals (like pizza or TV dinners)?

閣下每日會進食多少次罐頭食物，加工食物 (如薯片)，醃製肉類 (如煙肉)，或雪藏肉類 (如比薩餅)?



□ None 沒有 □ 1一次

□ 2 – 3 兩至三次 □ 4 – 5 四至五次

□ 6 or more 六次或以上





7. How many meals a week do you eat at restaurants or fast food places?

閣下每星期有多少次到酒樓或快餐店進食?

□ 1 or less 一次或更少 □ 2 – 3 兩至三次 □ 4 – 5 四至五次

□ 6 or more 六次或以上



8. How many servings of alcohol do you have on a typical day? One serving is a can of beer, a glass of

wine or a shot of hard liquor.

閣下每日飲酒的份量是多少?(1份等於1罐啤酒、XX)

□ 0 零 □ 1 一份 □ 2 兩份

□ 3 or more 三份或以上


9. Do you take calcium supplements on most days? 閣下有每日服用鈣片的習慣嗎?

□ Yes是 □ No否

10. Do you take a multivitamin or a B complex supplement on most days? 閣下有每日服用「多種維他命」或「維他命B複合物」的習慣嗎?

□ Yes是 □ No否

11. Do you take a multivitamin 4 or more days a week? 閣下有每日服用多種維他命的習慣嗎?

□ Yes是 □ No否

12. Do you take vitamin D supplements or calcium + vitamin D supplements on most days (apart from a

standard multivitamin)?

閣下有每日服用「維他命D」 或 「鈣+維他命D」 的習慣嗎?

□ Yes是 □ No否

Your Reproductive System

1. How old were you when you started your period? 閣下何時開始來經?

□ Younger than 15 十五歲前 □ 15 or older 十五歲或以後

2. Are you currently taking birth control pills?

閣下現在有沒有服用避孕藥?

□ Yes是 □ No否

3. How many children have you given birth to?

閣下生育了多少個兒女?

□ None 沒有 □ 1 一個 □ 2 兩個

□ 3 or more 三個或以上

4. How old were you when you first gave birth?

閣下第一次生育的歲數是:

□ Under 35 三十五歲前

□ 35 or older三十五歲或以後


5. Have you breastfed for a total of at least 1 year? If you have more than 1 child, this includes time

spent breast feeding all your children.

閣下是否有母乳餵養長達最少一年時間？如你有多於一個孩子

□ Yes是 □ No否

6. Have you gone through menopause (Have you stopped having menstrual periods)?

閣下正處於更年期嗎?

□ Yes. I became menopausal before the age of 55 是, 我於五十五歲前巳經處於更年期

□ Yes. I became menopausal at the age of 55 or older 是, 我於五十五歲或以後才處於更年期 □ No 否



7. Have you ever taken post-menopausal hormones? Post-menopausal hormones are medications to ease

the symptoms of menopause.

閣下是否曾服用停經荷爾蒙補充劑？停經荷爾蒙補充劑是一種藥物用作舒緩更年期帶來的不適。

□ No. I’ve never taken post-menopausal hormones. 沒有，我沒有服用停經荷爾蒙補充劑。

□ Yes. I’ve taken post-menopausal hormones for less than 5 years 有，我有少於五年的時間服用停經荷爾蒙補充劑

□Yes. I’ve taken post-menopausal hormones for 5 years or more. 有，我有五年或以上的時間服用停經荷爾蒙補充劑

8. What type of post-menopausal hormones have you taken?

閣下曾經服用哪種停經荷爾蒙補充劑？

□ I’ve taken estrogen alone (without progesterone) 我曾服用單一雌激素 (沒有黃體激素的成份) □ I’ve taken estrogen plus progesterone 我曾服用雌激素及黃體激素混合劑

□ I’ve taken both estrogen alone and estrogen with progesterone. 我曾服用單一雌激素及雌激素及黃體激素混合劑 □ I don’t know. 我不知道

9. How many male sexual partners have you had in your lifetime?

到目前為止，閣下有多少個男性性伴侶？

□ 0 零

□ 1 – 2 一至兩個

□ 3 or more 三個或以上

10. How old were you when you first had sex with a male partner?

閣下第一次與男性發生性行為的歲數是？

□ Younger than 16 少於十六歲 □ 16 or older 十六歲或以上




11. Throughout your life, has your primary method of birth control been a condom or diaphragm? 到目前為止，閣下的主要避孕方法是避孕套或子宮環？

□ Yes是 □ No否

12. Have you ever had an STI (sexually transmitted infection)? STIs include HPV (human

papillomavirus virus), herpes, gonorrhea, chlamydia and HIV/AIDS.

閣下是否曾患有性傳播疾病？這包括人類乳突瘤病毒，皰疹，淋病，衣原體病毒及人類免疫力缺乏病毒/愛滋病病毒。

□ Yes是 □ No否

I have read the above instructions and have completed the above questionnaire to the best of my knowledge and ability and vouch all the answers are factually correct. I authorize all doctors/hospitals to release all my medical information to AmMed Cancer Center.

本人已詳閱上述指示及以本人所盡知而填答此問卷, 並申明所有陳述乃為實情 ە 本人授權所有醫生/醫院發放本人全部醫療資料予安美癌科治療中心 ە



_______________________________ Date 日期: ______/_______/_______ Signature 簽署

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