乳癌篩查先導計劃(第二階段)篩選表 Breast Cancer Screening Pilot Programme(Phase II)Screening form

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服務單位：基督教聯合那打素社康服務

Service provider : United Christian Nethersole Community Health Service

了解更多合資格群體及服務提供者的資訊，請瀏覽： https://www.breastscreen.gov.hk/tc/

To know more about eligible groups and service providers,

please visit : https://www.breastscreen.gov.hk/en/

或致電衞生署專線：35863088

Or call the hotline of the Department of Health : 35863088

Email *

Record my email address with my response

姓名

Name

年齡

Age

聯絡電話

Contact number

欲預約服務的中心

District meeting venue

賽馬會天水圍社區健康中心(天水圍) Jockey Club Tin Shui Wai Community Health Centre(Tin Shui Wai)

賽馬會和樂社區健康中心(觀塘) Jockey Club Wo Lok Community Health Centre(Kwun Tong)

廣福社區健康中心(大埔) Kwong Fuk Community Health Centre(Tai Po)

佐敦健康中心(佐敦) UCN Jordan Health Centre(Jordan)

薈心醫務中心(九龍觀塘開源道79號鱷魚恤中心23樓2301B室) Holistic Wellness Medical Centre(Unit 01B, 23/F, Crocodile Centre, 79 Hoi Yuen Road, Kwun Tong, Kowloon)

電子健康記錄

Registered in eHealth Record system

已註冊 Yes

未註冊 (要加入該計劃必須註冊) Not yet (Must Registered to enroll into the progam)

有沒有乳癌症狀

Any symptoms of breast cancer

有 Yes (如有乳癌症狀則不符合參加本計劃的參加資格)

沒有 No

有沒有乳癌病史

Any history of breast cancer

有 Yes (如有乳癌病史則不符合參加本計劃的參加資格)

沒有 No

最近 1 年內做過乳房 X 光檢查

Any mammogram in recent 1 year

有 Yes (如1 年內做過乳房 X 光檢查則不符合參加本計劃的參加資格)

沒有 No

是否特定基因突變攜帶者(例如：BRCA1, BRCA2, CDH1, PALB2, PTEN, STK11, TP53, BARD1, NF1)

Carrier of certain genetic mutation (For example: BRCA1, BRCA2, CDH1, PALB2, PTEN, STK11, TP53, BARD1, NF1)

是 Yes

否/不清楚 No/Not sure

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