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Survey Proforma

Ongoing Project

Cancer Detection Society of India

Health Survey Questionnaire
Name	Age	Reg. No.
Address

Married	Yes/no	Childern No :
HABITS:-
Smoking Tobaccco Chewing Alcohol Drinking Veg./Non Veg.
HISTORY OF PAST ILLNESS		PROVISIONAL DIAGNOSIS
Family History
Present History
Blood in cough Blood in urine Blood in stool Blood in vomiting Blood through nose Change in voice Any swelling in the body Difficulty in swallowing menstrual history Bleeding during sex in female Vaginal discharge Loss of weight Loss of appetite Fever Fever with shivering Fever with pain in throat Fever mild in the evening Urinary incontinence Prolapsed rectum/uterus
Remarks of the Surveyors
Remarks of the Doctor
Investigations Advised

Projects:-
1.	Projects Done Click Highlights
2.	Projects being Done (on going projects)

	On Going projects (Join Us)

1.	Hospice Services Click Hospice page for details Home care services for terminally ill cancer patients
2.	Tibetan cause - Cancer Control Programme for Tibetans
3.	Cancer Services Centre & Hospice Services (Dharamshala)
4	Cancer Survey programme with European Commission
5.	Orphanage School - Free medical care of 350 orphans
6.	N.E.States - follow up cancer survey - Jan 03 on wards

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On Going projects (Join Us)