Breast Risk Assessment
Personal History
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Would you like to be contacted regarding your results?
*
Yes
No
DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Height
Weight
Age of your first period
Have you ever given birth?
Yes
No
Age at first birth
Have you ever had a breast biopsy?
Yes
No
If yes, what was the diagnosis?
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Next
MENOPAUSE: Are you...
Premenopausal (regular cycles)
Perimenopausal (intermittent cycles)
Post menopausal (No cycles)
If you are postmenopausal, at what age?
HYSTERECTOMY: Have you had one?
Yes
No
If you have had a hysterectomy, at what age?
HYSTERECTOMY: If you have had a hysterectomy, were your ovaries removed?
Yes
No
HORMONE THERAPY: Are you currently undergoing hormone therapy?
Yes
No
If yes, for how long and what type?
HORMONE THERAPY: Have you previously undergone hormone therapy?
Yes
No
If yes, for how long and what type?
HORMONE THERAPY: If yes, was it...
5 years ago or more
Less than 5 years ago
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Do you have a family history of ovarian cancer?
Yes
No
If yes, please share their relation to you and at what age they had ovarian cancer.
Do you have a family history of breast cancer? Please select all that apply.
Mother
Sister
Daughter
Maternal Grandmother
Maternal Aunt(s)
Maternal Cousin(s)
Paternal Grandmother
Paternal Aunt(s)
Paternal Cousin(s)
Other
If yes, please share who and at what age they had breast cancer.
Are you of Ashkenazi Jewish Decent?
Yes
No
Have you or your family been BRCA tested?
Yes
No
If yes, what were the results of your BRCA testing?
How did you hear about this?
Website (Infirmaryhealth.org)
Community Event
Flyer
Name of event
Submit
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