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Patient Survey

Oral Cancer Patient Survey

This survey is being conducted by the International Oral Cancer Association. The data collected will be used in our effort to increase the understanding and awareness of Oral Cancer. Your responses will not be disclosed with any personally identifiable information (e.g. name, e-mail address, etc.).

Your Information
We would appreciate it if you could provide your name for authenticity purposes. This data will not be released or shared.
Your Name*
Are you the Oral Cancer patient?*
- Yes
- No
Please describe your relation to the patient diagnosed with Oral Cancer.*
May we contact you regarding this, or future surveys?*
- Yes
- No
Please indicate if you would be open to future contact from the International Oral Cancer Association.
Your Email Address
Please enter your contact email address.
Your Phone Number
Please enter your contact phone number.
Patient Information
Please provide as much information as possible in this section, as incomplete data may not be usable.
Patient's Name
Entering the patient's name is optional.
Patient's Gender
- Male
- Female
- Other
Patient's Age
- Under 18
- 18-24
- 25-44
- 45-64
- 65-84
- 85+
Patient's City & Country
Please let us know what City & Country the patient lives in.
Patient's Zip or Postal Code
How often does the patient consume tobacco products?
- Never
- Every Month
- Every Week
- Every Day
How often does the patient consume alcohol?
- Never
- Every Month
- Every Week
- Every Day
How often is the patient sexually active?
- Never
- Every Month
- Every Week
- Every Day
How many times does the patient visit the dentist each year?
- 0-1
- 1-2
- 3-4
- 4+
How many times has the patient had an oral cancer screening examination?
- Never
- 1
- 2-3
- 4+
Patient's Oral Cancer Information
Please provide as much information as possible in this section, as incomplete data may not be usable.
What stage is the patient's Oral Cancer?
- Stage I
- Stage II
- Stage III
- Stage IV
How long has the patient been in this stage?
Please provide additional details about the patient's oral cancer here.
Is the patient seeking or under treatment?
- Seeking Treatment
- Undergoing Treatment
What kind of treatment is being used, and for what duration?
Please provide any additional information about the patient's treatment here.
How was the patient’s oral cancer diagnosed?
- Oral Cancer Screening
- Routine Visit
- Sought Treatment
- Emergency Care
About the patient's diagnosis
Please provide any additional information about the patient's diagnosis here.
Is the cause of the patient's cancer known?
- Yes
- No
Please describe the cause of the patient's Oral Cancer.

Patient Survey]

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