Breast Risk Assessment

This survey will help us to assess your risk for developing breast cancer. If you have already had breast cancer, this survey does not apply to you. Please read our disclaimer before taking the survey. Thank you.

Fields with an * are required.

*Name:
*Phone Number:

1. How old are you? 

2. What is your race? 

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

4. How old were you when your first child was born? (if you never had a child, enter "O.") 

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

6. Have you ever had a breast biopsy? (A breast biopsy is when the doctor removes tissue from your breast to test for cancer.)

If you have not had a biopsy, skip the next three questions:

6a. How many biopsies have you had?  

6b. Did the doctor ever tell you that one of your biopsies showed atypical hyperplasia (a pre-cancerous condition)?

6c. Did the biopsy show lobular carcinoma in situ (LCIS) or ductal carcinoma in situ (DCIS)?

Please allow 10 working days for turn-around time.

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1227 E. Rusholme Street Davenport, IA 52803 563-421-1000