Daedalos Institute, Ltd.                                              
A Health Informatics' Company                                                                                                                                                                    
 

Please describe, in English, your questions relating to your breast problems.

Then, Please,  fill the Breast Questionnaire below and summit it to us by clicking the submit button:

 Breast disease evaluation questionnaire

1. Your Date of Birth:

2. Your Doctors Name and Address:

3. Ethnic background:

4. At what age did you have your first menstrual period?

5. How many times have you been pregnant? (Miscarriages & Abortions included):

6. How many living children have you delivered?

7. How old were you with your first pregnancy?

8. Did you breastfeed? YesNo

9. If "Yes", for how long?

10. If you do not have periods anymore, how old were you when you had your the last period?

11. Has your uterus been removed?YesNo

12. If yes, at what age?

13. Did they remove your ovaries too? YesNo

14. Have you ever taken birth control pills? YesNo

15. If "Yes", how long  were you on birth control pills and what was the name of the medication you did take?

16. Currently taking birth control medication YesNo

17. If "Yes", what is the the name of your current the birth control medication.

18. Have you ever taken Premarin or other Estrogen, or hormones of any type? YesNo

19.  If "Yes", for how long?

20. Have you ever taken fertility drugs? YesNo

21. Do you do monthly breast self-examination? YesNo

22. When was you last Pap smear?

23. What was the results? NormalAbnormalBorderline

24. If not "Normal" please send us the report of your Pap smear by

25. Do you have breast pain?YesNo

26.  If "Yes", describe the character and duration of your breast pain.

25. Have you ever had a Mammogram? YesNo

26. If "Yes", what was the date of your last Mammogram?

27. Have you had an abnormal Mammogram? YesNo

28. If not "Normal", please send us the report of your mammogram by clicking Here .  

29. Have you ever had a breast biopsy? YesNo

30. If "Yes", how many?

31. Did any biopsy show "atypical ductal hyperplasia"? YesNo

32. Have you ever had nipple discharge?YesNo

33. If "Yes", of what color?

34. Did you ever have breast cancer? YesNo

35. If "Yes", what histological type?

36. If you can, send us the histological and the operative reports of your cancer surgery by 

37. Did your doctors suggested any treatment to you? YesNo

38. If "Yes", which of the follow ones?

Observation   

Fine Needle Aspiration   

Core-Needle biopsy

Stereotactic Biopsy    

Excisional Biopsy      

Wire Localization Biopsy

Lumpectomy or Partial Mastectomy with Axillary Dissection

Lumpectomy or Partial Mastectomy and Sentinel Node Biopsy

Modified Radical Mastectomy    

 Radical Mastectomy   

Simple Mastectomy 

Any Radiation before  Surgery   

Any Radiation after  Surgery   

Any Chemotherapy before  Surgery 

Any Chemotherapy after Surgery 

Any Hormonal Treatment after Surgery or after Chemotherapy

39. Any other treatments? YesNo

40. If "Yes", described it or send us your treatment plans

 by    

41. Did you have ever had any other cancer? YesNo

42.  If "Yes", in what organ of your body?

43. Do you currently have a breast lump or mass? YesNo

44. If "Yes", how was it detected? Self Breast ExaminationMammogramUltrsoundMY_doctorOther

45. Did you have any Ultrasound or Mammogram in the last 12 Months? YesNo

46. If "Yes", please send us your mammograms' reports

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

48. What was the result? NegativePositive

49. Have you ever had a sigmoidoscopy?YesNo

50. Have you ever had a colonoscopy YesNo

51. If "Yes", when and what were the findings?

52. Do you smoke? YesNo

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

54. How many packs per day?

55. Are you a former smoker? YesNo

56. If "Yes" when did you quit and why?

57. Do you drink alcoholic beverages? YesNo

58. If "Yes", what type how many drinks per week?

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

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

62. Please, describe your feelings about your potential risk of getting Breast Cancer:

 
 

63. In order to communicate with you, we need your Personal Identification Number or PIN:  

If you have not a PIN ,please,    to obtain a PIN:

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