Ovarian Cancer Risk Assessment
Please complete this form to help assess your risk factors for ovarian cancer. Your responses are confidential and will be used solely for risk evaluation purposes.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
Do you have a personal history of any of the following conditions?
*
Ovarian cancer
Breast cancer
Other cancer
None of the above
Has any close family member (mother, sister, daughter) been diagnosed with ovarian or breast cancer?
*
Yes
No
Not sure
Have you ever been tested for BRCA1 or BRCA2 gene mutations?
*
Yes, tested positive
Yes, tested negative
No, never tested
Not sure
Please indicate your reproductive history:
*
Never been pregnant
Had one or more pregnancies
Used fertility treatments
Used birth control pills for more than 5 years
None of the above
Please indicate if you have experienced any of the following symptoms in the last 6 months:
*
Rows
Never
Rarely
Sometimes
Often
Abdominal bloating or swelling
1
2
3
4
Pelvic or abdominal pain
5
6
7
8
Feeling full quickly when eating
9
10
11
12
Frequent urination
13
14
15
16
Do you currently smoke or have you smoked in the past?
*
Yes, currently smoke
Yes, smoked in the past
No
What is your current height (in centimeters)?
*
What is your current weight (in kilograms)?
*
On a scale of 1 to 10, how would you rate your perceived risk of developing ovarian cancer?
*
Very Low
1
2
3
4
5
6
7
8
9
Very High
10
1 is Very Low, 10 is Very High
Submit Assessment
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