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What is your age? | Under 30 | 1 | 30-40 | 2 | 41-50 | 3 | Above 50 | 4 |
At what age did you have your first menstruation? | Before 12 | 4 | 12-14 | 3 | 15-16 | 2 | Above 16 | 1 |
Do you have a regular menstrual cycle? | Yes | 2 | No | 4 | Irregular | 3 | Not sure | 1 |
Have you reached menopause? | Yes | 1 | No | 3 | Not yet | 2 | Not sure | 2 |
Do you have a family history of breast cancer? | Yes | 4 | No | 1 | Don't know | 2 | Not sure | 3 |
Do you have a history of breast disease? | Yes | 4 | No | 1 | Not sure | 2 | Not applicable | 0 |
Have you ever had breast surgery? | Yes | 5 | No | 1 | Not sure | 2 | Not applicable | 0 |
Have you had any previous breast cancer diagnoses? | Yes | 5 | No | 1 | Not Sure | 2 | Not Applicable | 0 |
Have you ever been diagnosed with ovarian cancer? | Yes | 5 | No | 1 | Not sure | 3 | Not applicable | 0 |
Have you ever used birth control pills? | Yes. for more than 5 years | 5 | Yes. less than 5 years | 3 | No | 1 | Not sure | 2 |
Have you had children? | Yes. more than 2 | 3 | Yes. 1-2 | 2 | No | 5 | Not Applicable | 0 |
Have you had a child after the age of 30? | Yes | 5 | No | 1 | Not applicable | 0 | Not sure | 2 |
Are you currently breastfeeding? | Yes | 1 | No | 3 | Not Applicable | 0 | Not Sure | 2 |
Do you experience breast pain? | Yes | 4 | No | 1 | Occasionally | 2 | Not sure | 3 |
When performing a self-exam. have you detected any unusual changes or lumps? | Yes | 5 | No | 1 | Not sure | 2 | Occasionally | 3 |
Have you ever felt pain or tenderness in your breast during self-examination? | Yes | 4 | No | 1 | Occasionally | 2 | Not sure | 3 |
Have you noticed any change in the size of your breasts? | Yes. significant change | 5 | Yes. minor change | 3 | No | 1 | Not sure | 2 |
Have you noticed any change in the appearance of your nipple? | Yes. such as inversion or discharge | 5 | Yes. slight change | 3 | No | 1 | Not sure | 2 |
Do you experience stiffness or pain around your nipple? | Yes. frequently | 5 | Occasionally | 3 | No | 1 | Not sure | 2 |
Have you noticed any hard lumps or nodules in your breast or around your armpit? | Yes. new lumps | 5 | Yes. existing lumps | 4 | No | 1 | Not sure | 2 |
Have you noticed any skin dimpling or puckering on your breast? | Yes | 5 | No | 1 | Occasionally | 3 | Not sure | 2 |
Have you experienced any redness or rash on your breast? | Yes. persistent | 5 | Yes. occasional | 3 | No | 1 | Not sure | 2 |
Have you noticed any swelling in your breast or around your armpit? | Yes. significant | 5 | Yes. minor | 3 | No | 1 | Not sure | 2 |
Do you experience any unusual discharge from your nipple? | Yes. blood or clear | 5 | Yes. yellow or green | 3 | No | 1 | Not sure | 2 |
Do you have any history of abnormal breast tissue? | Yes | 5 | No | 1 | Not sure | 3 | Not applicable | 0 |
Do you regularly undergo breast cancer screening? | Yes | 4 | No | 1 | Only when symptoms appear | 2 | Never | 0 |
Have you ever had a mammogram? | Yes. in the last year | 4 | Yes. 1-2 years ago | 3 | No | 1 | Not sure | 2 |
Have you ever been exposed to radiation? | Yes | 5 | No | 1 | Not sure | 3 | Not applicable | 0 |
Do you get sufficient exposure to sunlight? | Yes | 2 | No | 4 | Occasionally | 3 | Not sure | 1 |
Do you take vitamin D supplements? | Yes | 1 | No | 3 | Occasionally | 2 | Not applicable | 0 |
How often do you visit a doctor for general health check-ups? | Annually | 4 | Every 2-3 years | 2 | Occasionally | 3 | Never | 1 |
Have you ever had a biopsy? | Yes | 5 | No | 1 | Not sure | 2 | Not applicable | 0 |
What is your BMI? | Underweight | 1 | Normal weight | 2 | Overweight | 3 | Obese | 4 |
Are you on any long-term medications? | Yes | 3 | No | 1 | Not sure | 2 | Occasionally | 2 |
What is your level of stress? | High | 5 | Moderate | 3 | Low | 1 | Not sure | 2 |
How often do you get a flu shot? | Every year | 1 | Occasionally | 2 | Never | 3 | Not applicable | 0 |
Do you have any underlying health conditions? | Yes | 4 | No | 1 | Not sure | 2 | Occasionally | 3 |
Do you have any genetic mutations (BRCA1/BRCA2)? | Yes | 5 | No | 1 | Not sure | 3 | Not applicable | 0 |
Do you have any chronic inflammatory conditions? | Yes | 5 | No | 1 | Not sure | 3 | Occasionally | 2 |
Have you ever used hormone replacement therapy (HRT)? | Yes. for more than 5 years | 5 | Yes. less than 5 years | 3 | No | 1 | Not Sure | 2 |
Do you have a regular sleep schedule? | Yes | 4 | No | 1 | Occasionally | 2 | Irregular | 3 |
How many hours do you sleep per night? | Less than 5 hours | 5 | 5-7 hours | 3 | 7-9 hours | 2 | More than 9 hours | 1 |
Do you have a balanced diet? | Yes | 4 | Occasionally | 2 | No | 1 | Not sure | 3 |
How much red meat do you consume? | Daily | 4 | Weekly | 3 | Rarely | 2 | Never | 1 |
How much processed food do you consume? | Daily | 5 | Weekly | 3 | Rarely | 2 | Never | 1 |
How frequently do you consume dairy products? | Daily | 1 | Weekly | 2 | Rarely | 3 | Never | 4 |
Do you use artificial sweeteners? | Yes. regularly | 4 | Occasionally | 2 | No | 1 | Not sure | 3 |
How much fiber do you consume daily? | More than 30g | 1 | 20-30g | 2 | 10-20g | 3 | Less than 10g | 4 |
Do you use makeup or cosmetics regularly? | Yes | 3 | No | 1 | Occasionally | 2 | Not sure | 3 |
Do you smoke? | Yes. regularly | 5 | Occasionally | 3 | No | 1 | Quit | 2 |
Do you consume alcohol regularly? | Yes. more than 3 drinks a week | 5 | Occasionally | 3 | No | 1 | Never | 0 |
How often do you engage in physical activity? | Regularly (3-5 times a week) | 4 | Occasionally | 2 | Rarely | 1 | Never | 0 |
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