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Breast Cancer Risk Checklist by DenseBreast-info Inc.

Please print and complete the checklist, and bring with you to your next health checkup. This can help you and your doctor identify risks that may influence your breast cancer screening.

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Breast Cancer Risk Checklist by DenseBreast-info Inc.

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  1. AnEducationC oalition Breast Cancer RiskChecklist Breast cancerisacommondisease, affecting1in8Americanwomenat somepoint overtheirlifetime.Asthe twostrongest risksforbreast cancerarebeingfemaleandgettingolder, screeningisrecommendedforall women. The American Cancer Society and many other medical organizations recommend screening begin at age 40 and continue for as long as a woman is in good health. Discuss when your mammographyscreening should begin with your careprovider. Thoughmost breast canceroccursinwomenwithnoknownriskfactors, therearesomeriskfactorsknownto increasethechanceofgettingbreast cancer.Not allriskfactorscarrythesamelevelofriskandhavingarisk factor DOES NOT mean that you will definitely develop breastcancer. Please print and complete the checklist, and bring with you to your next health checkup. This can help you andyourdoctoridentifyrisksthat mayinfluenceyourbreast cancerscreening. Factors that mildly increaserisk: 1. Do you drink more than 5 oz. of alcohol daily (about the size of a glass of wine)? 2. Are you of Ashkenazi (Eastern European) Jewishheritage? 3. Has your mammogram indicated your breasts are heterogeneouslydense? ÆYes ÆNo ÆYes ÆNo ÆYes ÆNo Æ I don’t know my specific densitycategory 4. Did you begin getting your period at age 11 oryounger? 5. Did (do) you have any menstrual periods after age54? 6. Were you over 30 years old for your first full-termpregnancy? 7. I have had at least one full-term pregnancy (“no” = a mild increasedrisk) 8. Did you or your mother take diethylstilbestrol (DES) whilepregnant? 9. I have breastfed at least one child (“no” = mild increasedrisk) 10. If postmenopausal, has your weight increased since menopause, or have youbecome overweight orobese? 11. Haveyouhadabreast biopsy*withabenign/normal(e.g.fibroadenomaorfibrocysticchange) or nonatypicalresults? ÆYes ÆNo ÆYes ÆNo Æ Not applicable ÆYes ÆNo Æ Not applicable ÆYes ÆNo ÆYes ÆNo ÆYes ÆNo ÆYes, number of pounds gained ÆNo ÆNot applicable ÆYes ÆNo Factors that moderately increaserisk: 12. Have you already had breast cancer diagnosed at age 40 orover? 13. Haveyouhadabiopsy*withanatypicalorprecancerousresult( e.g.atypicalductalhyperplasia (ADH), atypical lobular hyperplasia (ALH) or atypicalpapilloma)? 14. Doesyourmammogramindicateyourbreastsareextremelydense? ÆYes ÆNo ÆYes ÆNo ÆYes ÆNo Æ I don’t know my specific densitycategory DenseBreast-info, Inc. PO Box 997, Deer Park, New York, 11729 501(c)(3) Public Charity I © 2015, DenseBreast-info, Inc. I ALL RIGHTS RESERVED www.DenseBreast-info.org Page 1 of2

  2. AnEducationC oalition Factors that moderately increaserisk: 15. Doyouhaveonefirst-degreerelative(mother,sister, ordaughter) diagnosedwithbreast cancer before age 50? If yes, please bring details of which relative(s) and age(s) ofdiagnoses to yourdoctor. 16. Do you have a family history of ovarian cancer? If yes, please bring details of which relative(s) and age(s) of diagnoses to yourdoctor. 17. Areyoupost-menopausalandtakingacombinationofestrogenandprogesteronehormonaltherapy? ÆYes. If yes, starting at what age and for how manyyears? 18. Do you have any male relatives (father, brother, or son) diagnosed with breastcancer? ÆYes ÆNo ÆYes ÆNo ÆNo ÆYes ÆNo Factors that strongly increaserisk: 19. Are you a woman 60 years of age orolder? 20. Doyouhaveanyknowndisease-causinggeneticmutationsforbreast cancer(e.g.BRCA1, BRCA2orother)? If yes, please share the results with your healthcareprovider. 21. Doanyfamilymembershaveanyknowndisease-causinggeneticmutationsforbreast cancer(BRCA1 or BRCA2)? If yes, please share the results with your healthcareprovider. 22. Were you diagnosed with breast cancer before the age of 40? 23. Doyouhavetwoormorefirst-degreerelatives(mom, sisterordaughter) diagnosedwithbreastcancer before age 50? If yes, please bring details of what relative(s) and at what age diagnosed to your doctor. ÆYes ÆNo ÆYes ÆNo ÆI don’t know ÆYes ÆNo ÆI don’t know ÆYes ÆNo ÆYes ÆNo 24. Haveyouhadhigh-doseradiationtreatment tochestbeforetheageof30(e.g.fortreatment for Hodgkinlymphoma)? 25. Do you have a personal history of ovariancancer? 26. Do you have a personal history of lobular carcinoma in situ(LCIS)? ÆNo ÆYes. How many yearsago? ÆYes ÆNo ÆYes ÆNo *If you have had a biopsy and do not know actual biopsy results,ASK. If you are taking medication to decrease your risk of developing breastcancer, please list that medicationhere: Any other issues/questions you would like to discuss with yourprovider: Thischecklist isforinformationalpurposesonlyandisnot intendedtobeasubstituteformedicaladvicefromaphysician. Pleasecheckwithaphysicianifyouneedadiagnosisand/orfortreatmentsaswellasinformationregardingyourspecificcondition. If you are experiencing urgent medical conditions, call 911 (in theU.S.). DenseBreast-info, Inc. PO Box 997, Deer Park, New York, 11729 501(c)(3) Public Charity I © 2015, DenseBreast-info, Inc. I ALL RIGHTS RESERVED www.DenseBreast-info.org Page 2 of2 Rvd 3/15

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