Breast Cancer Risk Assessment

1. How old are you?

2. What is your ethnic group? African American Asian Caucasian Hispanic Other

3. How much do you weigh? lbs.

4. How tall are you? Feet Inches

5. At what age did you have your first menstrual period?

6. If you are past menopause, how old were you when menopause began?

7. Have you had one or more children? Yes No

8. If you have had a child, how old were you when your first child was born?

9. Do you drink more than one alcoholic beverage a day? Yes No

10. Do you smoke? Yes No

11. If any women in your family have had breast cancer, check their relationship to you (check all that apply) Mother Daughter Sister No family history of breast cancer

12. Was your mother, sibling, or child diagnosed with breast cancer before the age of 45? Yes No

13. Have you had or do you have uterine cancer? Yes No

14. Have you had or do you have ovarian cancer? Yes No

15. Have you been told that you have certain gene mutations linked to breast cancer? Yes No

16. Has a mammogram shown that you have extremely dense breasts? Yes No

17. Have you been diagnosed with (check all that apply): Lobular carcinoma in situ (LCIS) Atypical ductal hyperplasia (ADH) Atypical lobular hyperplasia (ALH) None of these

18. Have you had radiation therapy to your chest to treat another type of cancer? Yes No

19. Are you currently taking combined hormone therapy (both estrogen and progesterone) to treat symptoms of menopause? Yes No

20. Have you taken the medicine diethylstilbestrol (DES), or did your mother take it while pregnant with you? Yes No

21. Are you currently taking hormone-based birth control, such as birth control pills? Yes No

Blanchard Valley Hospital

Bluffton Hospital

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