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SURVEY INTRODUCTION: Thank you for taking the time to complete this Breast Trauma Survey which will take between 5 and 10 minutes depending on the completeness of your responses. Your valuable response will assist in determining the association between breast trauma and breast cancer. In the United States, breast cancer is the most common form of cancer involving females. It is the second most common cause of cancer related death in women, and the main cause of death in women ages 40 to 59. Approximately one-half of breast cancer cases can be explained by known risk factors, such as age at menarche, first live birth, menopause, and proliferative breast disease. An additional 10 percent are associated with a positive family history. The lifetime probability of developing breast cancer is one in six overall (one in eight for invasive disease). Breast cancer kills. In order to show yet another risk factor for developing breast cancer, this survey is underway to gain beneficial information which you can assist with.
Again, thank you for your valuable time.

NOTICE OF PRIVACY AND DISCLAIMER: The below Breast Trauma Survey is not intended for personal medical treatment. The information obtained will be analyzed to determine if there is an association between breast trauma and breast cancer. This survey is to be taken anonymously. No identifiable information regarding any one individual will be available, accessible or released to any third party.

For additional information, please send an e-mail or call (334) 552-1119
1. What is your age? *
2. What is your Gender? *
3. What is your race? *
4. What is your Ethnicity? *
5. Do you or did you participate in sports?
6. What sport(s) did you participate in? *
7. Did you ever suffer trauma to your breast(s)?Trauma means any physical blow to the upper chest area. *
8. Which breast(s) suffered trauma?
9. Estimate the number of times there was trauma to the RIGHT breast.
Your answer
10. Estimate the number of times there was trauma to the LEFT breast.
Your answer
11. In what manner did you suffer trauma to the breast(s)? Fall
12. Please explain how the trauma to the breast(s) occurred.
Your answer
13. Do you perform monthly self-breast examinations? *
14. If you have performed a self-breast examination, have you discovered any areas on your examination of concern?
15. If you have discovered an area or area(s) of concern on your self-breast examination, which breast was involved? *
16. Have you had a mammogram for the detection of or screening for breast cancer?
17. If you have had a mammogram, how old were you when you had your first mammogram?
18. Please estimate the number of mammograms have you had in the past?
19. Have you had a mammogram that you considered to be particularly traumatic and/ or painful?
20. Have you ever had an abnormal mammogram?This would be any mammogram where you were asked to get additional follow-up due to some finding on the mammogram.
21. If you have had an abnormal mammogram, please briefly explain the finding.
Your answer
22. Have you had a Breast Ultrasound done? *
23. If an Ultrasound was done, what were the results?
24. If an ultrasound was done and was abnormal, please briefly explain the results.
Your answer
25. Have you been evaluated for the breast cancer gene BRCA1 or BRCA2?
26. If you have been evaluated for the breast cancer genes BRCA1 or BRCA2, what were the results?
27. If you have been found in the past to have breast cancer, was the cancer found to Estrogen / Progesterone (ER/PR) receptor positive?
28. Do you have a family history of breast cancer?
29. If a biopsy or resection of a breast mass was done, what was the outcome (if known)?
Your answer
30. Have you taken Estrogen replacement therapy in the past? *
31. Have you ever had exposure to ionizing radiation? *
32. Were you questioned by your doctor(s) regarding breast trauma at any time during the evaluation or diagnosis of possible breast cancer or treatment of your breast cancer?
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