Breast health screening questionnaire

No.

Yes

No

1.

Have you noticed any lump / mass / swelling in the breasts / armpits?

2.

Have you noticed any recent change in the size/ redness / warmth / thickening of the skin over the breast?

3.

Do you have any nipple discharge?

4.

Do you have any wound / ulcer / rash on the breasts / nipples?

5.

Have you noticed any change in the size / shape / feel of the breasts?

6

Have you had a breast biopsy, needle aspiration or surgery earlier?

7

Have any of your blood relatives suffered from breast / ovarian / any other cancer?

8

Did you have your first menstrual period before the age of 10 years?

9

Have you stopped having menstrual periods later than 50 years?

10

Have you never conceived or breast fed?

11

Have you ever taken any hormonal treatment for prolonged duration (oral contraceptive pills / hormone replacement therapy) Any treatment for infertility)?

12

Do you drink or smoke?

1.

Do you do a monthly breast self- examination?

2.

Do you undergo a physical breast examination by a doctor every year?

4.

Do you get mammograms / breast ultrasonography done every 1-2 years?