S.H.P.S.A.

Cancer Questionaire

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Name of person completing questionnaire:    ___________________________________

Contact number or address (optional):    _____________________

Name of person with cancer if different from above:    _______________________________________

Did she die of cancer?    Yes __        No __        [please check]

Date of birth of the person with cancer:    _________________

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?     Yes __        No __        [please check]

Did the person with cancer take Cookery to fifth form/grade 11?     Yes __        No __        [please check]

Did the person with cancer take Art to fifth form/grade 11?     Yes __        No __        [please check]

Did the person with cancer do any Science subjects?     Yes __        No __        [please check]

If so, which ones?    ___________________________

Is/was the person with cancer a smoker or non-smoker?    Yes __        No __        [please check]

Is/was the person with cancer a non-smoker living or working with a heavy smoker?    Yes __        No __        [please check]

Thank you for your time.