1. Are you exposed at work to polychlorinated biphenyls -- leather, metal (particularly aluminum), rubber and textile workers, painters, hair-dressers?
   Yes    No
2. Do you sweep chimneys for a living?
   Yes    No
3. Do you eat lots of fried meats and fats?
   Yes    No
4. Do you take vitamin A supplements regularly?
   Yes    No
5. Have you been a tobacco smoker within the last 10 years?
   Yes    No
6. Do you smoke tobacco now?
   Yes    No
7. Have you smoked tobacco for more than 10 years?
   Yes    No
8. Have you smoked tobacco for more than 20 years?
   Yes    No
9. Do you average more than one pack of cigarettes a day?
   Yes    No
10. Have you been taking cyclophosphamide (Cytoxan^®) for a long time?
    Yes    No
11. If you are a woman, have you had radiation treatment for cervical cancer?
    Yes    No
12. Have you ever had bilharziasis, a tropical disease caused by Schistosoma haematobium?
    Yes    No

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