Breast Cancer Risk Survey - The Womens Wellness Center of Wantagh - Womens Healthcare - Female Healthcare - DEXA bone densitometry Osteoporosis Evaluation - Incontinence Therapy

Take Our Breast Cancer Survey

Before you see the physician, please complete the survey below. It will help us to assess your risk for developing breast cancer.

1228 Wantagh Avenue
Wantagh, New York, 11793 USA
Tel. (516) 785-3129
Fax (516) 826-2632
coordinator@wantaghwellnesscenter.com

Breast Cancer Risk Survey

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Have you ever had breast cancer?: Yes No

If you have checked "yes", you have completed this survey.
Please give the survey to your health care provider.

Have you ever had a breast biopsy that showed lobular carcinoma in situ (LCIS) or ductal carcinoma in situ (DCIS)?: Yes No Don't Know

How old are you?

How old were you when you had your first menstrual period?

How old were you when your first child was born?
(If you never had a child, enter "0")

How many of your sisters, daughters, or mother have had breast cancer?

Have you ever had a breast biopsy? Yes No Don't Know
(A breast biopsy is when the doctor removes tissue from your breast to test for cancer.)

If yes, how many breast biopsies have you had?

Did the doctor ever tell you that one of your biopsies showed atypical hyperplasia (a precancerous condition)

Yes No Don't Know

What is your race? White Black Asian Other

Thank you for completing this survey. Please send this survey to your health care provider. The doctor will discuss the results with you.