Name *

First Name

Last Name

Do you you have any relatives with breast cancer? *

Yes

No

Have you ever been diagnosed with breast cancer? *

Yes

No

Have you ever been diagnosed with any other breast disease? (fibrocystic, mastitis, fibroadenoma, cysts, papillomas) *

Yes

No

Have you had any surgeries or biopsies to your breasts? *

Yes

No

Have you had any breast cosmetic surgery or implants? (augmentation, reduction, reconstruction, implants) *

Yes

No

Have you had a mammogram in the past 12 months? *

Yes

No

Have you had a mammogram in the past 5 years? *

Yes

No

Have you had any abnormal results from any breast testing? *

Yes

No

Have you ever taken a contraceptive pill for more than one year? *

Yes

No

Have you ever been diagnosed with a cancer of the womb? (cervical, uterine or endometrial) *

Yes

No

Have you ever taken pharmaceutical hormone replacement therapy? *

Yes

No

Do you have an annual physical examination by a doctor? *

Yes

No

Do you perform monthly self breast exams? *

Yes

No

Did your period begin before the age of 12? *

Yes

No

Do you still get your period? *

Yes

No

Do you smoke? *

Yes

Never

Not in last 12 months

Not in last 5 years

Please check if you have any of these breast symptoms? *

Right breast tenderness

Left breast tenderness

Right breast lump

Left breast lump

Right breast change in size

Left breast change in size

Right Breast areas of skin thickening or dimpling

Left breast areas of skin thickening or dimpling

Right breast secretions from the nipple

Left breast secretion from the nipple

None

By checking the box below, I certify that I have read and understand the statements above and consent to the examination. *