Get the free High Risk Questionnaire (Breast)

Saint Luke's Health System High Risk Questionnaire (Breast) Name: Date: 1. Reason for visit: Annual Screening 6 Month Follow Up Problem with Breast(s) Other: 2. Do you have a NEW problem with your

How to fill out high risk questionnaire breast

How to fill out high risk questionnaire breast:

1. Start by reading the instructions carefully. Make sure you understand the purpose of the questionnaire and what information is being requested.
2. Gather all necessary documents and records related to your medical history. This may include previous mammogram reports, biopsy results, family history of breast cancer, and any other relevant information.
3. Begin by providing your personal information, such as your name, age, address, and contact details. This will help the healthcare provider identify you and keep your records up to date.
4. Answer the questions regarding your family history of breast cancer. Be as accurate and specific as possible. Include information about any close relatives who have had breast cancer, their age at diagnosis, and any details regarding other types of cancers in your family.
5. Provide information about your personal medical history. This may include any previous breast biopsies, surgeries, or other breast-related procedures. Also, disclose any medication you are currently taking and any relevant medical conditions you have been diagnosed with.
6. Answer questions related to lifestyle factors that may increase your risk of developing breast cancer. These may include questions about your alcohol consumption, smoking habits, physical activity levels, and use of hormone replacement therapy.
7. If applicable, provide information about any previous mammograms you have had. Include the date, location, and results of the mammogram. This will help the healthcare provider track any changes in your breast health over time.
8. Finish by reviewing your answers and making any necessary corrections. Double-check that you haven't missed any questions or provided inaccurate information. It's important to be as thorough as possible to ensure an accurate assessment of your breast cancer risk.

Who needs high risk questionnaire breast:

1. Women with a family history of breast cancer: If you have a close relative, such as a mother, sister, or daughter, who has been diagnosed with breast cancer, you may be considered at high risk.
2. Women with a genetic mutation: Certain genetic mutations, such as BRCA1 or BRCA2, significantly increase the risk of developing breast cancer. If you have tested positive for these mutations, you will likely need to fill out a high-risk questionnaire.
3. Women with a personal history of breast cancer: If you have been previously diagnosed with breast cancer, even if it was successfully treated, you may still be at high risk for developing a new or recurrent breast cancer.
4. Women with certain breast conditions: Certain breast conditions, such as atypical hyperplasia or lobular carcinoma in situ, can increase your risk of developing breast cancer. Your healthcare provider may recommend filling out a high-risk questionnaire if you have been diagnosed with these conditions.
5. Women with other risk factors: Other factors, such as a history of radiation therapy to the chest area, early onset of menstruation, late onset of menopause, or hormone replacement therapy, may also increase your risk of breast cancer. Your healthcare provider can determine if you need to fill out a high-risk questionnaire based on these factors.

For pdfFiller’s FAQs

What is high risk questionnaire breast?

High risk questionnaire breast is a screening tool used to assess a person's risk of developing breast cancer based on their personal and family medical history.

Who is required to file high risk questionnaire breast?

Individuals with a family history of breast cancer or other risk factors may be required to fill out a high risk questionnaire breast by their healthcare provider.

How to fill out high risk questionnaire breast?

To fill out a high risk questionnaire breast, individuals should provide detailed information about their personal medical history, family medical history, lifestyle factors, and any other relevant information requested by their healthcare provider.

What is the purpose of high risk questionnaire breast?

The purpose of a high risk questionnaire breast is to help identify individuals who may be at an increased risk of developing breast cancer, so that appropriate screening and prevention measures can be implemented.

What information must be reported on high risk questionnaire breast?

Information that must be reported on a high risk questionnaire breast includes personal medical history, family medical history, lifestyle factors, and any other relevant risk factors for breast cancer.

Where do I find high risk questionnaire breast?

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