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                By Dr. Suraj Verma MBBS. MS. FICS. (USA)
                   President Cancer Detection Society of India

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Survey Proforma

Ongoing Project
Cancer Detection Society of India
Health Survey Questionnaire
Name Age Reg. No.
Married Yes/no Childern No :
  • Smoking
  • Tobaccco Chewing
  • Alcohol Drinking
  • Veg./Non Veg.
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 Done      Click Highlights

2. Projects being Done  (on going projects)

On Going projects      (Join Us)


 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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