Date of Birth: Month January February March April May June July August September October November December Day 12345678910111213141516171819202122232425262728293031 Year 1930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975 (This information is required to generate your estimated breast cancer risk, since age is a risk factor. The program calculates risk for women ages 35 thru 84.)
Race: Caucasian / White African-American / Black Hispanic / Latina Other If Other, Specify: (Race is a factor in determining your individualized risk. If you are of mixed racial/ethnic background, choose the category with which you most closely identify.)
If adopted, click here
Does/Did her mother have breast cancer? yes no Not sure
Does/Did her daughter(s) have breast cancer? yes no Not Applicable/Not sure
If Yes, Number of daughters with breast cancer 123456789101112131415
Does/Did her sister(s) have breast cancer? yes no Not Applicable/Not sure
If Yes, Number of sisters with breast cancer 123456789101112131415