Breast Cancer Risk Questionnaire

Are you at high risk for getting breast cancer? If you are 35 years old or older, please take this quiz:

Did you have your first period before age 12?

Yes, enter 1 here: ________

No, enter 0 here: ________

Did you have your first child after age 30?

Yes, enter 1 here: ________

No, enter 0 here: _________

Are you childless?

Yes, enter 1 here: _______

No, enter 0 here: ________

Did/does your mother have breast cancer?

Yes, enter 2 here: _________

No, enter 0 here: __________

Do you have any sisters who have had or have breast cancer?

Yes, enter 2 here: _________

No, enter 0 here: __________

Do you have any daughters who have had or have breast cancer?

Yes, enter 2 here: _______

No, enter 0 here: _______

Have you ever had a breast biopsy? (A breast biopsy is when the doctor removes tissue from your breast to test for cancer.)

Yes, enter 2 here: _______

No, enter 0 here: ________

Did the doctor ever tell you that one of your biopsies showed a premalignant or precancerous condition?

Yes, enter 2 here: ________

No, enter 0 here: _________

Did the doctor ever tell on that one of your biopsies showed early cancer that has not spread yet?

Yes, enter 2 here: _________

No, enter 0 here: _________

Add the numbers in the right hand column from questions 1 – 9

If your answers add up to 2 or more, you may be at high risk for developing breast cancer. Contact us to evaluate you further. Please talk to Dr. Gurley about taking the new Breast Cancer Risk Assessment test (Gail test). This test consists of several questions and only takes a few minutes. It is an important test that can estimate your chances of getting breast cancer.

If your answers add up to less than 2, for now you may only need to continue with regular breast self-exams, regular mammograms, and regular breast exams conducted by your doctor. Because simply being a woman and getting older put you at risk for breast cancer, be sure to take this quiz again in the future.

This test is meant for educational purposes only. It is not a substitute for a medical consultation with a qualified health professional.