Breast Cancer Risk Assessment Form
Full Name
Age
Email Address
Gender
Female
Male
Other
Family History of Breast Cancer
No
Mother
Sister
Other relatives
Have you had any of the following?
Previous Breast Cancer
Previous Ovarian Cancer
Radiation Therapy to Chest
Age at First Menstrual Period
Age at First Full-term Pregnancy
Have you ever taken hormonal therapy?
Yes
No
Do you regularly perform breast self-exams?
Yes
No
Have you undergone genetic testing for BRCA1/2?
Yes
No