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Breast History and Risk Assessment Form Breast Center of Acadian Name: DOB: Age: Date: Referring MD: Other MDs you have seen related to any breast problems (surgeon, oncologist, radiation oncologist):

How to fill out breast history and risk

How to fill out breast history and risk:

1. Gather all relevant information: Before filling out the breast history and risk form, gather all necessary information pertaining to your personal medical history and family history of breast cancer. This may include past diagnoses, treatments, surgeries, and medications related to breast health.
2. Complete the personal information section: Begin by providing your full name, date of birth, contact information, and any other requested personal details.
3. Answer the screening questions: The form may ask a series of screening questions related to your breast health. These questions are designed to assess your risk factors for breast cancer. Be honest and provide accurate information to ensure a comprehensive evaluation.
4. Provide details on past diagnoses or breast abnormalities: If you have previously been diagnosed with any breast conditions, such as benign tumors or breast cancer, provide details including dates, treatments received, and outcomes.
5. Family history: The form may inquire about your family history of breast cancer. Enter information about close relatives (parents, siblings, children) who have had breast cancer or any other breast-related conditions. Include their relationship to you and the age at which they were diagnosed.
6. Environmental and lifestyle factors: You may be asked about certain factors that can influence breast cancer risk, such as exposure to radiation, hormone replacement therapy, alcohol consumption, smoking, or physical activity. Answer accurately to help assess your overall risk.

Who needs breast history and risk?

1. Women of all ages: Breast history and risk assessment is important for women of all ages. The risk of developing breast cancer increases with age, but screening and understanding risk factors should start early in life.
2. Those with family history: Individuals with a family history of breast cancer, especially in close relatives, are at a higher risk of developing the disease. Understanding and documenting this history can help healthcare providers determine the appropriate screening and preventive measures.
3. Those with personal history: Individuals who have previously been diagnosed with breast abnormalities or breast cancer should have a detailed breast history and risk assessment. This information can aid in determining further treatment options and appropriate follow-up care.
4. Women with specific risk factors: Certain factors, such as inherited genetic mutations (e.g., BRCA1 and BRCA2), previous chest radiation therapy, or hormonal imbalances, can increase the risk of developing breast cancer. Women with these risk factors should undergo a breast history and risk assessment to determine the best course of action for early detection and prevention.
5. Anyone seeking proactive healthcare: Even if you do not have any specific risk factors or a family history of breast cancer, it is still important to fill out a breast history and risk assessment form. It allows healthcare providers to evaluate your individual risk profile and recommend appropriate screening guidelines based on your age, overall health, and other relevant factors.

For pdfFiller’s FAQs

What is breast history and risk?

Breast history and risk refers to the documentation and assessment of a person's personal and family history related to breast cancer, as well as the evaluation of potential risk factors for developing the disease.

Who is required to file breast history and risk?

Individuals who are at risk for breast cancer or have a family history of the disease are typically required to fill out breast history and risk forms.

How to fill out breast history and risk?

To fill out breast history and risk forms, individuals must provide detailed information about their personal medical history, any previous diagnoses of breast cancer, and any family history of the disease.

What is the purpose of breast history and risk?

The purpose of breast history and risk assessment is to identify individuals who may be at higher risk for developing breast cancer, so that appropriate screening and preventative measures can be implemented.

What information must be reported on breast history and risk?

Information that must be reported on breast history and risk forms typically includes personal medical history, family history of breast cancer, genetic testing results, and any known risk factors for the disease.

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