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IBCCP Health Assessment
Name
(Required)
First
Last
Date
(Required)
Breast Health Questions
1. Do you routinely check your breasts for changes?
Yes
No
2. Have you noticed a lump in your breasts?
Yes
No
3. If yes, which breast?
Right
Left
4. Have you noticed any breast tenderness or pain?
Yes
No
5. If yes, did the breast tenderness or pain increase around the time of your menstrual period?
Yes
No
6. If you answered yes to question #4, which breast?
Right
Left
7. Have you noticed any spontaneous discharge (not from stimulation or squeezing) from your nipples?
Yes
No
8. If yes, which breast?
Right
Left
9. Have you noticed any other symptoms related to your breasts?
Yes
No
9a. If yes, explain
10. Have you ever had a breast exam done by a doctor or nurse?
Yes
No
11. If yes, list provider/clinic where breast exam was done
12. If yes, date of last exam (before this current visit)
13. Have you ever had a mammogram?
Yes
No
14. If yes, list provider/clinic where mammogram was done
15. If yes, date of your last mammogram (before this current visit)
15a. Check if date of last mammogram is unknown
Date unknown
16. If unknown, was it more than 5 years?
Yes
No
17. Have you ever had breast cancer?
Yes
No
18. Has your mother, father, sibling (sister/brother), daughter or son had breast cancer?
Yes
No
19. If yes to #18, who
20. Are they BRCA positive? (if unknown, leave blank)
Yes
No
Unknown (leave blank)
21. If yes to #18, at what age?
Age in years
22. Do you have a breast implant or implants?
Yes
No
23. Have you ever had a breast biopsy, breast cyst aspiration or surgery on your breast?
Yes
No
24. If yes, which breast?
Right
Left
25. If yes, list the provider who performed the procedure
26. Have you ever had radiation to the chest area?
Yes
No
Cervical Health Questions
27. Have you ever had a Pap test?
Yes
No
28. If yes, list provider where Pap test was done
29. If yes, date of last Pap test (before this current visit)
29a. Check if date of last Pap test is unknown
Date unknown
30. If date unknown, was it more than 10 years ago? Please guess and write the date in #29.
Yes
No
31. Were your last Pap test results normal?
Yes
No
32. What was the date of your last menstrual period?
33. Are you pregnant?
Yes
No
34. Have you had a hysterectomy?
Yes
No
35. If yes, was your cervix removed?
Yes
No
I do not know
36. If you had a hysterectomy, was it due to a past history of cervical disease or cervical cancer?
Yes
No
37. Were you exposed to Diethylstilbestrol (DES)?
Yes
No
38. Is your immune system weakened in any way? (medication, HIV, organ transplant or other health condition)
Yes
No
Tobacco Questions
39. Do you smoke cigarettes?
Yes
No
40. If yes, are you ready to quit smoking?
Yes
No
41. If yes, are you interested in being referred to the Illinois Tobacco Quitline?
Yes
No
Office Use Only
42. What date was the referral sent to the Tobacco Quitline?
Barrier/Risk Assessment Questions
43. Barrier Assessment
From Eligibility Determination form
44. Life time risk
From Summary Office Visit form
45. High risk for breast cancer
Yes, client is high risk
No, client is not high risk
Not assessed/unknown
46. High risk for cervical cancer
Yes, client is high risk
No, client is not high risk
Not assessed/unknown
