➢ Choose your gender
➢ How old are you? ___years old
➢ What is your race?
➢ Enter your height & weight
o Height ___meter
o Weight ___kg
➢ Have you ever been diagnosed with below non-invasive tumors?
Please tick if you are diagnosed with non-invasive tumor(s).
o Lobular Carcinoma in Situ (LCIS) [ ]
o Ductal Carcinoma in Situ (DCIS) [ ]
➢ How many benign breast biopsies have you had?
o 2 or more
Why kind of benign breast biopsies?
o Hyperplasia with Atypia
o Hyperplasia without Atypia
o Hyperplasia with Atypia & positive family history
➢ Do you have any cytology results below?
o Proliferation with Atypia
o Proliferation without Atypia
o Proliferation with Atypia & positive family history
➢ Are you diagnosed with breast cancer at 1 breast?
➢ Your mammograms show dense breast tissue.
Ursin et. Al (2003) suggests mammographic density as a strong predictor of risk for African-American and Asian-American women as for white women. It is assumed that this factor also strong in Asian women.
How dense is your breast?
Hormonal & Reproductive Factor
➢ Have you ever used oral contraceptive or currently taking it?
o Never taking it
o Currently taking it
o Have taken but already stop for less than 5 years
o Have taken but already stop for 5-9 years
o Have taken but already stop for 10 years or more
Enter your age of first time use ___ years old
➢ Have you ever used hormone replacement therapy (HRT) or currently taking...