What is your first name?
What is your gender?
Female
Male
What is your age?
Has anyone in your family been diagnosed with breast cancer?
No
Yes. One immediate family member (mother, sister, daughter).
Yes. More than one immediate family member (mother, sister, daughter).
Don’t know
What was the result of your last mammogram?
Negative/Normal
Benign Finding
Probably Benign
Suspicious Finding
Highly Suggestive
Never had a mammogram
Don’t know
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