Breast Health Survey

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1. How old are you?

20 years & younger

21-30 years

31-40 years

41-50 years

51 years & above

Please select your age.

2. What irregularities in the size of the breast(s) did you notice?

Unequal breast size

Swelling

None of the above

Please select an option.

3. Which of the following nipple issues did you notice ?

Discharge

Cracked nipple

Inverted/Retracted nipple

None of the above

Please select an option.

Grade of Inversion:

Grade 1: The nipple can easily be pulled out and will stay out

Grade 2: The nipple can be pulled out but retracts back after you let it go

Grade 3: The nipple is completely inverted and cannot be pulled out at all, even with pressure

4. Did you notice any of these changes in your breasts ?

Dimpling

Redness

Clusters o bulging veins

None of the above

Please select a grade.

5. During the breast exam, did you feel any lumps or nodules within your breasts?

Yes

Please select Yes or No.

6. Do you identify yourself as:

Underweight

Normal weight

Overweight

Obese

Please select your weight category.

7. At what age did your period start?

<9 years

10-15 years

>16 years

I don't remember

Please select the age at which your period started.

8. Have you ever been pregnant?

Yes

Please select if you have ever been pregnant.

9. Have you ever used oral contraceptives or been on hormonal therapy for any reason?

Yes

Please select whether you have used oral contraceptives or hormonal therapy.

10. Have you ever had a mammogram?

Yes

Please select if you have ever had a mammogram.

Was your mammogram normal?

Yes

I am not sure

11. Was your mammogram normal?

Yes

I am not sure

Please select whether your mammogram was normal.

12. Have you undergone surgery to remove your uterus or ovaries?

Uterus was removed

Ovaries were removed

Ovaries & uterus were removed

None of the above

Please select an option regarding your surgery.

13. Have you had any of the following breast procedures?

Needle

Breast biopsy

Removal of a breast or entire breast

Radiation therapy

None of the above

Please select an option regarding breast procedures.

14. Has anyone in your immediate family been diagnosed with breast cancer or ovarian cancer?

Yes

Please select an option regarding family history.

15. Do you consume alcohol?

Occasionally

Everyday

I don't drink

Please select your alcohol consumption status.

Full Name Full Name is required.

Email Address Email Address is required. Please enter a valid email address.

Contact Number Contact Number is required.

Age Age is required. Please enter a valid age.