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BREAST CANCER SCREENING: HISTORY AND RISK ASSESSMENTName: ___ DOB: ___ Age: ___ Date: ___Referring Doctor: ___If you would, you like to have your breast imaging report sent to another doctor(s) please list them here: ______1. Is this your first mammogram?

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How to fill out breast history and risk

01

Gather all relevant medical records and family health history.

02

Provide detailed information about any past breast conditions or surgeries.

03

List any medications or supplements that may impact breast health.

04

Complete all sections of the breast history form accurately and honestly.

05

Discuss any concerns or questions with a healthcare provider.

Who needs breast history and risk?

01

Individuals with a family history of breast cancer or other breast conditions.

02

Those undergoing screenings for breast cancer.

03

People with a personal history of breast abnormalities or surgeries.

04

Those with risk factors for breast cancer such as age, genetic mutations, or hormonal factors.

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What is breast history and risk?

Breast history and risk refers to the detailed medical history and assessment of potential risk factors related to breast cancer.

Who is required to file breast history and risk?

Individuals with a personal or family history of breast cancer are usually required to file breast history and risk information.

How to fill out breast history and risk?

The form for breast history and risk can typically be filled out online or submitted through a healthcare provider.

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, allowing for early intervention or preventive measures.

What information must be reported on breast history and risk?

Information such as personal medical history, family history of breast cancer, genetic testing results, and lifestyle factors may need to be reported on breast history and risk forms.

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