Breast Cancer Screening Form

Your Information

First Name

Last Name

Date of Birth

Current Age

Phone Number

Address

City

State

Zip Code

If other, please specify:

Gender at Birth MaleFemale

Have you ever been diagnosed with breast cancer? YesNoUnknown

Have you ever had radiation treatments to your chest region? YesNoUnknown

Have you ever been told by a healthcare provider that you have dense breast tissue? YesNoUnknown

Are you currently having any of the following symptoms?

Choose all that apply, hold SHIFT to select multiple.

Do you have a family history of breast cancer, particularly a first-degree relative (i.e. mother, sister)? YesNoUnknown

Do you have a known genetic mutation associated with breast cancer (i.e. BRCA1 or BRCA2)? YesNoHave Not Been Tested

Have you ever had a mammogram? YesNoUnknown

Do you have a primary care provider? YesNoUnknown

If yes, name of primary care provider.

How did you hear about this cancer risk survey?

Choose all that apply, hold SHIFT to select multiple.

I Acknowledge and Consent that by submitting this form, you agree to understanding that this risk assessment is for educational and informational purposes only. It is not a medical diagnosis or treatment. Participation in this cancer screening program allows your information to be used to assess health risks and provide follow-up recommendations. Participation is also voluntary and can be withdrawn at any time. You must select this checkbox to submit this form.

Baptist Health Mission

Breast Cancer Screening Form

Breast Cancer Screening Form