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Breast Cancer Risk
Assessment Survey
(Yes = 1, No = 0) |
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| 1. |
Are you older
than 50? |
| 2. |
Did you have your first
menstrual period before age 12? |
| 3. |
Did you have your first child
after age 30? |
| 4. |
Are you childless? |
| 5. |
Has your mother had breast
cancer? |
| 6. |
How many of your sisters have
had breast cancer? |
| 7. |
How many of your daughters
have had breast cancer? |
| 8. |
Have you ever had a breast
biopsy? |
| 9. |
How many breast biopsies
(positive or negative) have you had? |
| 10. |
Have you ever had a breast
biopsy with atypical hyperplasia? |
Scoring:
Every time you answered "Yes", give yourself one point.
For other questions the score is the number given. Add up the total
points.
According to this survey, based on the Gail Model, anyone that scores a 2
or higher should see their health care professional soon, to review and
discuss the results. Take this survey with you when you visit your Doctor.
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