Breast Health Assessment screening FORM

The Tyrer-Cuzick model is a breast cancer risk assessment tool incorporating family history, endogenous hormonal factors, benign disease, risk factors such as age and body mass index, as well as genetic factors (including BRCA) into a single statistical model. The Tyrer-Cuzick model has been shown in independent studies to be the most consistently accurate when compared with other available risk assessment models.

Please fill out the fields in the form below and click submit. It will be sent to one of our staff for review and evaluation.

Or, click here to download and print out the form. You may fill it out and mail it back to the address listed on the bottom of the form.

Name

First Name

Last Name

Street Address

City, State, Zip Code

Phone number

E-mail Address

Current Age, Weight (pounds) and Height (feet and inches)

What was your age when you had your first menstrual period?

Have you given birth to one or more children?

If YES, what age where you when you delivered your first child?

Have you gone through menopause?

If YES, at what age did you go through menopause?

Hormone Replacement Therapy (HRT) useage?

HRT: If less than five years ago OR current user:

Choose one option below.

Length (in years) of HRT use?

Choose one

BRCA Gene: Do you have a mutation in either the BRCA1 or BRCA2 gene?

OVARIAN CANCER: Have you had ovarian cancer?

If YES, at what age where you diagnosed?

BREAST Biopsy: Have you had a breast biopsy? Check all that apply.

No prior biopsy/no proliferative disease

Prior biopsy, result unknown

Hyperplasia (not atypia)

Atypical Hyperplasia

Lobular Carcinoma in Situ (LCIS)

FAMILY HISTORY: Ashkenazi inheritance?

Family history is an important factor in determining risk, especially if there is a history of breast or ovarian cancer in the woman's family.