Women’s Cancer Risk Assessment Form
A comprehensive self-assessment to help you understand factors that may influence your risk for women’s cancers. This form is for informational purposes only and does not collect sensitive health information.
What is your age group?
*
Please Select
Under 30
30–39
40–49
50–59
60 or older
Have any of your close relatives (mother, sister, daughter) been diagnosed with breast, ovarian, or uterine cancer?
*
Yes
No
Not sure
Have you ever been diagnosed with any type of cancer?
*
Yes
No
How often do you engage in physical activity (such as walking, running, or exercise)?
*
Rarely or never
1–2 times per week
3–4 times per week
5 or more times per week
Do you currently smoke or have you smoked in the past?
*
Never smoked
Former smoker
Current smoker
How often do you consume alcoholic beverages?
*
Never
Occasionally
Regularly (1–2 times per week)
Frequently (3 or more times per week)
At what age did you have your first menstrual period?
*
Please Select
Under 12
12–14
15 or older
Not sure
Have you ever been pregnant?
*
Yes
No
Have you had a mammogram or Pap smear in the past 3 years?
*
Mammogram
Pap smear
Neither
How would you rate your awareness of common symptoms of women’s cancers?
*
1
2
3
4
5
Submit Assessment
Should be Empty: