Breast Cancer Risk Assessment Name * First Name Last Name Date of Birth * MM DD YYYY What is your current weight? * What is your height? * Do you have a history of breast cancer or of ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS)? * Yes No Have you received previous radiation therapy to the chest for treatment of Hodgkin lymphoma? * Yes No Age at first menstrual period? * Have you given birth to one or more children? * Yes No If yes, what age were you when you had your first live birth? Have you gone through menopause? (Menopause is defined as 12 months after last menstrual period or spotting.) * Yes No In menopause now If yes, at what age did you go through menopause? Hormone replacement therapy (HRT) usage: * Never Stopped use 5 or more years ago Stopped use less than 5 years ago Current user If you stopped HRT use in the last five years or are a current user, estrogen only or combined treatment? Estrogen only Combined If you stopped HRT use in the last five years or are a current user, length (in years) of HRT use? Unknown 1 year 2 years 3 years 4 years 5 years 6 years More than 6 years If not a current user, how many years ago did you last use HRT? 0 years 1 year 2 years 3 years 4 years 5 years If a current user, how long do you intend to be using HRT? Unknown 1 year 2 years 3 years 4 years 5 years 6 years More than 6 years Do you have a mutation in either the BRCA1 or BRCA2 gene? * Unknown Tested, normal BRCA1+ BRCA2+ Have you had ovarian cancer? * Yes No If yes, at what age were you diagnosed? Have you had a breast biopsy? Check all that apply. * No prior biopsy Prior biopsy, result unknown Hyperplasia (not atypia) Atypical Hyperplasia Lobular Carcinoma in Situ (LCIS) Have you ever had a breast biopsy with a benign (not cancer) diagnosis? * Yes No If yes, how many breast biopsies with a benign (not cancer) diagnosis? 1 2 or more Ashkenazi inheritance? * Yes No Family history of relatives with breast cancer? * Yes No If yes, name the family member's relation to you: ex: maternal aunt, paternal grandmother, etc. If yes, what is their current age or age at death? If yes, what was their age at diagnosis? If yes, bilateral? Yes No If bilateral, age at diagnosis of 2nd breast? Family history of relatives with ovarian cancer? * Yes No If yes, name the family member's relation to you: ex: maternal aunt, paternal grandmother, etc. If yes, what is their current age or age at death? If yes, what was their age at diagnosis? Family history of BRCA gene testing? * Yes No If yes, name the family member's relation to you: ex: maternal aunt, paternal grandmother, etc. If yes, what is their current age or age at death? If yes, BRCA gene? Unknown Tested, normal BRCA1+ BRCA2+
