1. Are you over 50 years old?
Yes
No

2. Any family history of stomach cancer?
Yes
No

3. Do you smoke?
Yes
No

4. Do you often eat smoked, fried, or processed foods?
Often
Sometimes
Rarely

5. Do you feel stomach discomfort after eating?
Frequently
Occasionally
Never

6. Have you been diagnosed with Helicobacter pylori?
Yes
No / Don’t know

7. Have you ever had blood in your stool or unexplained anemia?
Yes
No