Frankford Hospitals - Center for Gynecology & Women’s Health at Frankford Hospitals

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Center for Gynecology & Women’s Health at Frankford Hospitals

Breast Cancer Risk Assessment

Women can answer the following questions to get a sense of their
likelihood of having or developing breast cancer.

Are you over the age of 40?	Yes	No
Do you have a mother, daughter, or sister (or male relative) who has had breast cancer?	Yes	No
Were you younger than 12 when you had your first period?	Yes	No
Were you older than age 55 when you went through menopause?	Yes	No
Are you over 40 and never had children?	Yes	No
If you have children, were you over the age of 30 when you had your first child?	Yes	No
Has it been longer than one year since your last breast exam by a healthcare provider?	Yes	No
Are your over age 40 and has it been longer than one year since your last mammogram?	Yes	No
Have you ever had to have a surgical biopsy of your breast tissue?	Yes	No
Have you ever been diagnosed with breast problem?	Yes	No
Have you had any localized pain or change in appearance of a breast?	Yes	No
Do you have any previous personal history of breast or ovarian cancer?	Yes	No
Have you ever had chest radiation for any other type of cancer?	Yes	No
Have you had long-term hormone replacement therapy?	Yes	No
Do you consume the equivalent of more than two alcoholic drinks per day?	Yes	No
Have you become overweight as an adult?	Yes	No
Do tend to have an inactive lifestyle?	Yes	No
Are you Caucasian?	Yes	No

The more often you answered “Yes” to the above questions, the greater your risk for developing breast cancer. If you answered “Yes” to questions above, consider discussing breast cancer with one of our Women’s Center healthcare providers.

Print this page and bring it with you, filled out, to your appointment.

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