Assessment of breast cancer risk form

1. Your Personal Identification Number or PIN:              If you have not a PIN, please click Here

2. What is your ethnic background:

3. Have you ever had any cancer?YesNo 

4. If yes, what type of cancer?

5. If it was Breast Cancer, please fill and submit to us the Breast Cancer Evaluation Form as well.

6. When did you last have your stool checked for blood?

7. What was the result? YesNo

8. Have you ever had a sigmoidoscopy?YesNo

9. Have you ever had a colonoscopy YesNo

10. If yes when and what were the findings?

11. Do you smoke? YesNo

12. If yes, how many years have you smoked?

13. How many packs per day?

14. Are you a former smoker? YesNo

15. If yes when did you quit?

16. Do you drink alcoholic beverages? YesNo

17 If yes, how many drinks per week?

18. What do you think is your risk of getting cancer?Very lowAverageSomewhat higher than averageMuch higher than average

19. How concerned are you about your risk of getting  cancer?Not at allRarely worryOccasionally worryVery worriedWorry constantly

Family Medical History

20. How many sisters do you have?  

21. How many brothers?

22. How many sisters does your mother have?  

23. How many brothers does your mother have?

24. How many sisters does your father have?

25. How many brothers?

26. Has anyone in your family had cancer?YesNo

27. If "Yes", please fill the form below commenting if more than one person is involved in a category.

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