The California Department of Public Health
offers a sample Breast Cancer History and Risk Assessment
Form, suitable for use in any clinic providing screening
services.
This form offers a systematic approach for
gathering and recording key information needed for
determining a patient’s breast cancer risk and
plan of action. It is intended to be completed by the
patient and reviewed by the clinician with the patient.
The
questionnaire can be used in conjunction with the Risk
Assessment Table (see Breast
Cancer Diagnostic Algorithms) to help identify
women who may be at increased risk of developing breast
cancer.
Download the form now!
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