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Women Cancer Awareness
State Life Cancer Awareness Week - Questionaire
Hospital Name
District
Form No.
46478
Demographic Profile
Name
Age
Cnic
Contact
Occupation
Education Level
No formal education
Primary
Secondary
Higher Education
Residential Area
Rural
Urban
Marital Status
Married
Unmaried
Ever Been Pregnant
Yes
No
NA
Breast Feeding
Yes
No
NA
Hormone Replacement Therapy Or Contraceptive
Yes
No
NA
Breast Cancer Survey
Family History Of Cancer
NO
CA Breast
HCC
CA Prostate
CA Colon
Lymphoma
Any Other
Who In Your Family Been Diagnosed With Breast Cancer
Self
Mother
Daughter
Sister
Any Other Relation
None
Ever Get Examined
Self-Examination
Mammogram Done
CT Scan Done
Biopsy Done
Not Examined
NA
Are You Aware Of The Symptoms Of Breast Cancer ( e.g, lump, discharge, skin, changes)?
Yes
No
Where Did You Get Information About Breast Cancer Screening Camp?
Media
Internet
Family
Friends
Hospitals
Breast cancer Screening Checklist
Breast Lump
Yes
No
Breast Lump Size
Less then 2cm
2cm-5cm
Greater than 5cm
NA
Breast Lump Texture
Soft
Hard
NA
Skin Changes
Dimping
Redness
Thickening
NA
Nipple Changes
Inversion
Discharge
NA
Breast Size/shape
Any Changes
Asymmetry
NA
Breast Pain
Persistent
Non-Cyclic
NA
Lymph Nodes
Swollen
Non-Swollen
NA
Ulceration
Yes
No
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