https://www.onrevenue.us/components/com_company/uploaded_images/1741734139_logo500pix.png

Risk Assessment Questions

Please answer the following questions so we may be able to determine from your medical history and your family history if you are at high risk for the following diseases.

Female Cancer:

Cervical Vaginal Breast

Were you sexually active before the age of 16 years?

Yes No

Have you had more then five sexual partners in your life?

Yes No

Have you ever had a sexually transmitted disease?

Yes No

Have you had fewer than 3 negative pap smears in the past 3 years?

Yes No

Did your mother take DES(diethylstibestrol) during pregnancy ?

Yes No

Do you have a history of breast cancer?

Yes No

What is you current age?

What was your age at the time of your first menstrual period?

What was your age at the first live birth of a child?

How many first degree relatives (mother, sisters, daughters) have had breast cancer ?

Have you ever had a breast biopsy?

Yes No

What is your race?

White Black Asian Other

Heart Disease

Have you had a first degree relative (father,brothers) that has had a heart attack before the age of 45?

Yes No

Have you had a first degree relative (mother, sisters) that has had a heart attack before the age of 55?

Yes No

Are you overweight?

Yes No

Do you smoke?

Yes No

Do you have diabetes?

Yes No

Do you have hypertension (high blood pressure)?

Yes No

What is your current age?

* These questions are required by Medicare in order to determine if the pelvic, pap, and breast exams will be covered every year or every 3 year.