First Name
Last Name
Phone
Email
*
Do you know your risks for developing breast cancer?
Yes
No
Do you know how to lower your risk of breast cancer?
Yes
No
Do you know how to perform a self-breast exam?
Yes
No
How often do you perform a self-breast exam?
Never
Less than monthly
Monthly
What scares you about doing a self-breast exam?
Not knowing how to do it correctly
Finding a lump
Nothing
Do you have a personal or family history of breast or ovarian cancer?
Yes- breast personal hx
Yes- ovarian personal hx
Yes- breast family hx
Yes- ovarian family hx
Both- family
No
Have you had BRCA 1 & 2 testing?
Yes
No
Have you or a family member tested positive for BRCA 1 or 2?
Yes
No
I do not know
Do you get a mammogram every year?
Yes
No
Have you ever had a breast MRI?
Yes
No