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This is a self declaration form to be filled by the user taking the early detection oral cancer test.This test is a saliva based early detection test kit and helps in detecting Oral pre cancer in its early stages.The whole point of testing and detection at this point is to make sure the problem could be caught early and the person would be saved from all the suffering and pain which happens when detecting at later stages.

Email:

Unique Kit Number:

Name:

Age:

Gender:

Contact number:

Address:

Through the below fields we want to know you better in terms of your health,diet,lifestyle and few other things.Please feel free to skip those which are not mandatory.

Do let us know if you are into any of these.

SmokingTobaccoAlcoholBetel NutNone

If you are into any of the above like smoke,tobacco or alcohol.Since how long you have been indulged in it?

Less then 2 yearFrom 2 - 5 yearsMore then 5 years

How often do you use them?

Heavy ( > 3 cigarettes ( consider any form of smoke a day ) , > 2 times of tobacco chewing (which includes any type of chewable tobacco) , > 50 ml of alcohol consumption daily, > 2 times of Betel nut chewing ( includes plain betel nuts, flavoured betel nuts, Pan and its other forms )Moderate ( < 3 cigarettes ( consider any form of smoke a day ) , < 2 times of tobacco chewing (which includes any type of chewable tobacco) , < 50 ml of alcohol consumption daily, < 2 times of Betel nut chewing ( includes plain betel nuts, flavoured betel nuts, Pan and its other forms )Light ( These are occasional consumers who smoke, drink or chew tobacco once or twice in a week and sometimes go on for months without indulging in any consumption. They only have it on occasions like when meeting friends or colleagues during weekends in parties.)

Have you included exercises, yoga, morning or evening walks, jogging, running or cycling as an integral part of your daily routine?

YesNo

Is there a family history of Cancer in your family?

YesNoDon’t Know!

Do you have any health ailments which you want us to know?

Thyroid DisorderDiabetesBlood PressureCardiovascular DiseaseChronic Kidney Disease (CKD)Liver DisorderGastric ProblemAutoimmune DiseasesUrinary Tract InfectionAIDSNone of the above

Is there any ulcer inside your mouth or a cut/wound which is not healing?

YesNo

Have you undergone any oral treatment or surgery or are you using some form of metal dentures?

YesNo

Are you experiencing any pain while opening your mouth, pain in your jaw line, swollen gums, pain in tongue, unexplained bleeding of gums, discomfort while swallowing anything?

YesNo

Lastly just to make sure that we don't hurt Corona's feelings.It would be good to know this.

FeverCoughProblem BreathingHave travelled to other city in past monthNone