FOR YOUR OWN GOOD HEALTH, PLEASE ANSWER THESE QUESTIONS.
BREAST CANCER RISK SURVEY
Before you see your doctor, here is a sample Breast Cancer Survey with questions that he or she may ask. Please fill in and take to your physician.

PATIENT NAME: ________________AGE_____DATE:_________

PATIENT INSTRUCTIONS:
The survey below will help your doctor or health care provider to assess your risk for developing breast cancer.

Have you ever had breast cancer? Yes___ No___
If checked “yes,” you have completed this survey. Please give the survey to your health care provider

Have you ever had a breast biopsy that showed lobular carcinoma in situ (LCIS) or ductal carcinoma in situ (DCIS)?
Yes___ No___ I Don’t know____

1. How old are you?
   Age ______
2. How old were you when you had your first menstrual period?
   Age ______
3. If you have any children, how old were you when your first child was born?
   Age_______
4. If any, how many of your sisters, daughters or mother have had breast cancer?
   Age_______
5. Have you ever had a breast biopsy?
   (A breast biopsy is when the doctor removes tissue from your breast to test for cancer.)
   Yes___ No___ I Don’t know____
6. a. If yes, how many breast biopsies have you had?
   No.______
7. b. Did the doctor ever tell you that one of your biopsies showed atypical hyperplasia (a precancerous condition or anything else abnormal)?
   Yes___ No___ I Don’t know____
8. What is your race?
   Hispanic____ Black____Asian____Other______

Thank you for completing this survey. Please give the survey to your doctor or health care provider. The doctor will discuss the results with you.