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BREAST HISTORY QUESTIONNAIRE Name: Date of Birth Referring Doctor: Tech Use ONLY: *PLEASE CIRCLE YES OR NO TO EACH QUESTION×Yes Have YOU had previous mammograms? Where? When? Have YOU given birth?
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How to fill out breast history questionnaire

01
Start by obtaining a breast history questionnaire form.
02
Read the instructions and familiarize yourself with the questions before filling out the form.
03
Begin by providing your personal information, such as your name, date of birth, and contact details.
04
Answer the questions about your family history of breast cancer. Provide information about your parents, siblings, and other relatives who have had breast cancer or any other breast-related conditions.
05
Answer questions about your own medical history, including any previous breast surgeries, biopsies, or mammograms you may have had.
06
If you have been diagnosed with breast cancer in the past, provide details about your diagnosis, treatment, and outcomes.
07
Complete any additional sections or questions that may be present on the form, such as lifestyle factors or hormonal therapies.
08
Review your answers for accuracy and completeness before submitting the completed breast history questionnaire.

Who needs breast history questionnaire?

01
Anyone who is required to provide a comprehensive history of their family's breast cancer or breast-related conditions may need to fill out a breast history questionnaire. This includes individuals who have a personal history of breast cancer or have close relatives who have been diagnosed with breast cancer. Medical professionals, researchers, and institutions may also require patients or participants to fill out a breast history questionnaire to gather data for studies or genetic research purposes.
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The breast history questionnaire is a form used to gather information about an individual's personal and family history of breast cancer or related conditions.
Individuals who are at risk for breast cancer or have a family history of the disease are typically required to fill out a breast history questionnaire.
To fill out a breast history questionnaire, individuals need to provide accurate information about their personal medical history, family history, and any previous breast cancer screenings or diagnoses.
The purpose of the breast history questionnaire is to help healthcare providers assess an individual's risk for breast cancer and determine if further screening or genetic testing is warranted.
Information that should be reported on a breast history questionnaire includes personal medical history, family history of breast cancer or related conditions, previous breast cancer screenings or diagnoses, and any known genetic mutations.
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