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Information
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Age:
Sex:
Male
Female
Marital Status:
Married
Unmarried
Are you sexually active:
Yes
No
Have you had breast cancer before?:
Yes
No
Do you know anybody affected by breast cancer?:
Yes
No
Are they alive or dead?:
Living
Not Living
Your relationship:
Do you know about breast self exams (BSE)?:
Yes
No
Have you ever done it?:
Yes
No
Do you know about mammograms?:
Yes
No
Have you ever had one?:
Yes
No
If no, why not?:
Number of children you have:
Age at which first child was born:
Age of your first menses:
Have you had any abortions?:
Yes
No
Did you know that abortions increase the risk of breast / cervical cancer?:
Yes
No
Have a concern?:
May we contact you?:
Email:
Phone:
Address:
Name (first name):
Best time to reach you:
