S.H.P.S.A.

Cancer Questionnaire

If you have been diagnosed with cancer or know of a fellow past student who has been so diagnosed, please copy and paste the questionnaire below into an e-mail and address it to jpalmertomlinson@yahoo.com or print and complete the form and post, under confidential cover, to :

Dr. Janice Palmer-Tomlinson

26 Wellington St.

Spanish Town

St. Catherine

Jamaica

W.I.

Incomplete forms will be accepted.

Information provided will be held in the strictest confidence.

    Click here for Printable Version to open in a new window

Name of person completing questionnaire:

Contact number or address (optional):

Name of person with cancer if different from above:

Did she die of cancer? :

Date of birth of the person with cancer (yy/mm/dd) :

Years of attendance of the person with cancer at St Hugh’s High School:
19         to

Year of diagnosis of cancer:

Type of cancer:

Primary site of the cancer:

Did the person with cancer live at the Hostel? :

Did the person with cancer take Cookery to fifth form/grade 11? :

Did the person with cancer take Art to fifth form/grade 11? :

Did the person with cancer do any Science subjects?:
If so, which ones? :

Is/was the person with cancer a smoker or non-smoker?:

Is/was the person with cancer a non-smoker living or working with a heavy smoker? :



Thank you for your time.