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MAMMOGRAPHY QUESTIONNAIRE Rev 012317DATE NAME DATE OF BIRTH AGE 1. Yes No Have you had a mammogram before? When: Where: 2. Yes No Do you have any breast problem today? If yes, please explain: 3. Yes
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Rev 01-23-17 is a specific revision or version of a document, form, or report that was created or updated on January 23, 2017.
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