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What is your age?
|
Under 30
| 1 |
30-40
| 2 |
41-50
| 3 |
Above 50
| 4 |
At what age did you have your first menstruation?
|
Before 12
| 4 |
12-14
| 3 |
15-16
| 2 |
Above 16
| 1 |
Do you have a regular menstrual cycle?
|
Yes
| 2 |
No
| 4 |
Irregular
| 3 |
Not sure
| 1 |
Have you reached menopause?
|
Yes
| 1 |
No
| 3 |
Not yet
| 2 |
Not sure
| 2 |
Do you have a family history of breast cancer?
|
Yes
| 4 |
No
| 1 |
Don't know
| 2 |
Not sure
| 3 |
Do you have a history of breast disease?
|
Yes
| 4 |
No
| 1 |
Not sure
| 2 |
Not applicable
| 0 |
Have you ever had breast surgery?
|
Yes
| 5 |
No
| 1 |
Not sure
| 2 |
Not applicable
| 0 |
Have you had any previous breast cancer diagnoses?
|
Yes
| 5 |
No
| 1 |
Not Sure
| 2 |
Not Applicable
| 0 |
Have you ever been diagnosed with ovarian cancer?
|
Yes
| 5 |
No
| 1 |
Not sure
| 3 |
Not applicable
| 0 |
Have you ever used birth control pills?
|
Yes. for more than 5 years
| 5 |
Yes. less than 5 years
| 3 |
No
| 1 |
Not sure
| 2 |
Have you had children?
|
Yes. more than 2
| 3 |
Yes. 1-2
| 2 |
No
| 5 |
Not Applicable
| 0 |
Have you had a child after the age of 30?
|
Yes
| 5 |
No
| 1 |
Not applicable
| 0 |
Not sure
| 2 |
Are you currently breastfeeding?
|
Yes
| 1 |
No
| 3 |
Not Applicable
| 0 |
Not Sure
| 2 |
Do you experience breast pain?
|
Yes
| 4 |
No
| 1 |
Occasionally
| 2 |
Not sure
| 3 |
When performing a self-exam. have you detected any unusual changes or lumps?
|
Yes
| 5 |
No
| 1 |
Not sure
| 2 |
Occasionally
| 3 |
Have you ever felt pain or tenderness in your breast during self-examination?
|
Yes
| 4 |
No
| 1 |
Occasionally
| 2 |
Not sure
| 3 |
Have you noticed any change in the size of your breasts?
|
Yes. significant change
| 5 |
Yes. minor change
| 3 |
No
| 1 |
Not sure
| 2 |
Have you noticed any change in the appearance of your nipple?
|
Yes. such as inversion or discharge
| 5 |
Yes. slight change
| 3 |
No
| 1 |
Not sure
| 2 |
Do you experience stiffness or pain around your nipple?
|
Yes. frequently
| 5 |
Occasionally
| 3 |
No
| 1 |
Not sure
| 2 |
Have you noticed any hard lumps or nodules in your breast or around your armpit?
|
Yes. new lumps
| 5 |
Yes. existing lumps
| 4 |
No
| 1 |
Not sure
| 2 |
Have you noticed any skin dimpling or puckering on your breast?
|
Yes
| 5 |
No
| 1 |
Occasionally
| 3 |
Not sure
| 2 |
Have you experienced any redness or rash on your breast?
|
Yes. persistent
| 5 |
Yes. occasional
| 3 |
No
| 1 |
Not sure
| 2 |
Have you noticed any swelling in your breast or around your armpit?
|
Yes. significant
| 5 |
Yes. minor
| 3 |
No
| 1 |
Not sure
| 2 |
Do you experience any unusual discharge from your nipple?
|
Yes. blood or clear
| 5 |
Yes. yellow or green
| 3 |
No
| 1 |
Not sure
| 2 |
Do you have any history of abnormal breast tissue?
|
Yes
| 5 |
No
| 1 |
Not sure
| 3 |
Not applicable
| 0 |
Do you regularly undergo breast cancer screening?
|
Yes
| 4 |
No
| 1 |
Only when symptoms appear
| 2 |
Never
| 0 |
Have you ever had a mammogram?
|
Yes. in the last year
| 4 |
Yes. 1-2 years ago
| 3 |
No
| 1 |
Not sure
| 2 |
Have you ever been exposed to radiation?
|
Yes
| 5 |
No
| 1 |
Not sure
| 3 |
Not applicable
| 0 |
Do you get sufficient exposure to sunlight?
|
Yes
| 2 |
No
| 4 |
Occasionally
| 3 |
Not sure
| 1 |
Do you take vitamin D supplements?
|
Yes
| 1 |
No
| 3 |
Occasionally
| 2 |
Not applicable
| 0 |
How often do you visit a doctor for general health check-ups?
|
Annually
| 4 |
Every 2-3 years
| 2 |
Occasionally
| 3 |
Never
| 1 |
Have you ever had a biopsy?
|
Yes
| 5 |
No
| 1 |
Not sure
| 2 |
Not applicable
| 0 |
What is your BMI?
|
Underweight
| 1 |
Normal weight
| 2 |
Overweight
| 3 |
Obese
| 4 |
Are you on any long-term medications?
|
Yes
| 3 |
No
| 1 |
Not sure
| 2 |
Occasionally
| 2 |
What is your level of stress?
|
High
| 5 |
Moderate
| 3 |
Low
| 1 |
Not sure
| 2 |
How often do you get a flu shot?
|
Every year
| 1 |
Occasionally
| 2 |
Never
| 3 |
Not applicable
| 0 |
Do you have any underlying health conditions?
|
Yes
| 4 |
No
| 1 |
Not sure
| 2 |
Occasionally
| 3 |
Do you have any genetic mutations (BRCA1/BRCA2)?
|
Yes
| 5 |
No
| 1 |
Not sure
| 3 |
Not applicable
| 0 |
Do you have any chronic inflammatory conditions?
|
Yes
| 5 |
No
| 1 |
Not sure
| 3 |
Occasionally
| 2 |
Have you ever used hormone replacement therapy (HRT)?
|
Yes. for more than 5 years
| 5 |
Yes. less than 5 years
| 3 |
No
| 1 |
Not Sure
| 2 |
Do you have a regular sleep schedule?
|
Yes
| 4 |
No
| 1 |
Occasionally
| 2 |
Irregular
| 3 |
How many hours do you sleep per night?
|
Less than 5 hours
| 5 |
5-7 hours
| 3 |
7-9 hours
| 2 |
More than 9 hours
| 1 |
Do you have a balanced diet?
|
Yes
| 4 |
Occasionally
| 2 |
No
| 1 |
Not sure
| 3 |
How much red meat do you consume?
|
Daily
| 4 |
Weekly
| 3 |
Rarely
| 2 |
Never
| 1 |
How much processed food do you consume?
|
Daily
| 5 |
Weekly
| 3 |
Rarely
| 2 |
Never
| 1 |
How frequently do you consume dairy products?
|
Daily
| 1 |
Weekly
| 2 |
Rarely
| 3 |
Never
| 4 |
Do you use artificial sweeteners?
|
Yes. regularly
| 4 |
Occasionally
| 2 |
No
| 1 |
Not sure
| 3 |
How much fiber do you consume daily?
|
More than 30g
| 1 |
20-30g
| 2 |
10-20g
| 3 |
Less than 10g
| 4 |
Do you use makeup or cosmetics regularly?
|
Yes
| 3 |
No
| 1 |
Occasionally
| 2 |
Not sure
| 3 |
Do you smoke?
|
Yes. regularly
| 5 |
Occasionally
| 3 |
No
| 1 |
Quit
| 2 |
Do you consume alcohol regularly?
|
Yes. more than 3 drinks a week
| 5 |
Occasionally
| 3 |
No
| 1 |
Never
| 0 |
How often do you engage in physical activity?
|
Regularly (3-5 times a week)
| 4 |
Occasionally
| 2 |
Rarely
| 1 |
Never
| 0 |
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