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Carcinoma of the breast and risk factors among patient

attending early detection centers


1- Age:-

2- Residence:-

3- Occupation:-

4-Education:- primary ( ) secondary ( )


Collage ( ) Non educated ( )
5- Marital state:-
6- Socio-economic state;- low( ) : moderate ( ): high( )

7- Number of children:- No children( ): 1-2 children ( ): 3-4


children ( ) or more than 4 ( )

8- Breast feeding:-
9- History of chronic diseases;- HT ( ) : DM ( ) :Asthma ( )
10- Family history of CA breast (first degree relative) :( )

11- Drug history :Anti HT: ( ) Anti DM ( )

12- Smoking ; low (<10 cig./day) ( )moderate(10-20 cig./day)


heavy (>20 cig./day) non-smoker( )
ex-smoker ( )
13- Oral contraceptive pill :-

14- Blood grouping:- ( ) RH+ ( ) : RH- ( )

15- Previous exposure to chest x-ray:( ) How many time ( )

16- Body mass index (BMI) :- A-Height:-


B-Weight:-
17- Age of menarche ;- ( ) Age of menopause:- ( )

18- History of infertility ;-( ) How long duration :- ( )