Breast Cancer Risk Assessment & Prevention

Personal Information

About You

First name *

Last name *

Are you calling for yourself, or on behalf of someone else? * For myself For someone else

Date of birth * (mm/dd/yyyy)

About The Patient

Patient's first name *

Patient's last name *

Patient's date of birth *

Your relationship to the patient *

Your Phone Number * (###-###-####)

Have you Has the patient ever been seen at Roswell Park? Yes No

Patient MRN

How did you hear about Roswell Park?

Please explain *

General Information

Your The Patient's Contact Information

Your Patient's Phone number * (###-###-####)

Alternate phone (###-###-####)

Your Patient's Email Address *

Best time to call

Would you the patient like to join our mailing list? Yes No

Your Patient's Insurance Information Optional

Primary insurance provider

ID number (Letters and Numbers only)

Secondary insurance provider

ID number (Letters and Numbers only)

Your The Patient's Physician Information Optional

Primary physician

Primary physician's phone (###-###-####)

Referring physician

Referring physician's phone (###-###-####)

Risk Assessment

Family History

Are youIs the patient of Ashkenazi Jewish ancestry? * Yes No Unsure

Has a parent, sibling or child of the patient's ever been diagnosed with breast cancer? * Yes No

If yes, ELIGIBLE

Select all family members that have been diagnosed with breast cancer * Mother Father Sister(s) Brother(s) Daughter(s) Son(s)

Have at least two of the patient's aunts/uncles/grandparents/first cousins ever been diagnosed with breast cancer? * Yes No

If yes, ELIGIBLE

Select all extended family members that have been diagnosed with breast cancer * Aunt(s) Uncle(s) Grandparent(s) First Cousin(s)

Prior Cancer & Treatment History

Do youDoes the patient have a history of breast cancer? * Yes No/Unsure

Have youHas the patient had radiation treatment to yourthe chest for Hodgkin Lymphoma? * Yes No/Unsure

If yes, ELIGIBLE

Mammography

Have youHas the patient had an abnormal mammogram? * Yes No/Unsure

Have youHas the patient had a mammogram within the last year? * Yes No/Unsure Never had one

Month of last mammogram *

Year of last mammogram *

Where was yourthe patient's last mammogram? *

General Health

Do youDoes the patient have a lump in yourhis/her breast? * Yes No/Unsure

Are youIs the patient currently having regular periods? * Yes No/Unsure

Do youDoes the patient have a history of LCIS or atypia on breast biopsy? * LCIS = Lobular Carcinoma In Situ, a benign (not cancer) condition Yes No/Unsure

If yes, ELIGIBLE

Your Patient's Residential Address

Personal Information

About You

About The Patient

General Information

Your The Patient's Contact Information

Your Patient's Insurance Information Optional

Your The Patient's Physician Information Optional

Risk Assessment

Family History

Prior Cancer & Treatment History

Mammography

General Health