Women's Cancer Network

About the Gynecologic Cancer Foundation

About the Women's Cancer Network

WCN Editorial Contributors

WCN Senior Advisory Committee

Press Releases

Disclaimer

Tuesday, September 16, 2008

Home > 1

WCN Risk Questions

Cancer Risk Assessment Survey

This confidential, interactive survey, developed by gynecologic cancer experts, will help you to identify your risk level for developing breast cancer, ovarian cancer, endometrial cancer, cervical cancer, vulvar cancer, and vaginal cancer.

The survey contains questions about your personal background and medical history, reproductive history, use of hormones, family history of cancer, lifestyle, and cancer screening practices. After you complete the survey, a customized report will be immediately prepared for you, indicating your approximate degree of risk for developing each of these cancers. This report will include useful recommendations on how to manage and reduce your risk of developing these cancers. There are also links for a description of each risk factor.

Remember that your risk assessment is based upon the answers you provide today. If your health history changes, please visit again and repeat the survey to obtain a revised risk assessment.

Simply answer the questions below and in less than 10 minutes you will have a better sense of your risk for developing many common cancers and be able to take better control of your health. These survey pages have been optimized to be used with Microsoft Internet Explorer.

Please make sure you answer every question, even if your answer is in the negative.

Click on the underlined portion of each question to find out why it is important in determining your risk.

Personal History

The following are demographic questions about yourself.

1. What is your age?

2. What is your ethnic group?

3. What is your religion?

4. What is your highest level of education?

5. What is your annual household income?

6. What is your weight (lbs)?

7. What is your height (feet & inches)?

Personal Medical History

The next questions are about your own personal medical history.

8. Have you ever been diagnosed with any type of cancer (besides non-melanoma skin cancer)?
yes no If "no", skip 9.

9. If you answered "yes" to the previous question, enter what type of cancer(s) you have been diagnosed with (check all that apply) and the age you were diagnosed.

Breast	Age:
Cervix	Age:
Colorectal	Age:
Endometrial	Age:
Hodgkin's disease	Age:
Lung	Age:
Ovary	Age:
Vulvar	Age:
Vaginal	Age:
Other	Age:

10. Have you had any of the following surgeries? Questions 11,12 & 13:
yes no     If "no", skip 11,12,13.

11. To remove your uterus (hysterectomy)? yes   Age:

12. To remove your ovaries (oophorectomy)?   Age:

13. Have you had a tubal ligation (tubes tied)? yes

14. Have you ever been diagnosed with benign breast disease that resulted in a breast biopsy? (Benign breast disease includes moderate or atypical hyperplasia BUT NOT cysts, fibrocystic disease, fibroadenoma, or mild hyperplasia)
yes no

15. How many breast biopsies have you had?

16. Have you ever had an abnormal Pap test?
If "No" or "Never had a PAP", skip 17-21.

Have you had any of the following treatments for an abnormal Pap test?   Check all that apply.

17. With antibiotic creams

18. Colposcopy with biopsy

19. Cryotherapy (freezing of cervix)

20. Laser therapy

21. Surgery

Have you ever been diagnosed with any of the following precancerous conditions?   Check all that apply.

22. Cervical intraepithelial neoplasia (CIN)

23. Vulvar intraepithelial neoplasia (VIN)

24. Vaginal intraepithelial neoplasia (VAIN)

Have you ever been diagnosed with any of the following?    Check all that apply.

25. Amenorrhea (absence of menstrual periods)

26. Diabetes

27. Hepatitis B or C

28. High blood pressure (hypertension)

29. HIV/AIDS

30. Infertility (tried to get pregnant for at least 2 years)

31. Kidney disease (chronic)

32. Lupus

33. Polycystic ovary disease

34. Rheumatoid arthritis

Reproductive History

The next series of questions are about your reproductive history

35. How old were you when you first started having your menstrual periods?

36. Over your lifetime, would you describe your menstrual periods as usually:

37. How many times have you been pregnant?

38. How many live births have you had?

39. How old were you when you had your first baby?

40. Have you breastfed for a total of 1.5 years or more (includes the time you breastfed all of your children)?
yes no

41. Are you still having your menstrual periods?
yes no

42. At what age did you stop having your menstrual periods?

The next questions are about your use of hormones

43. Have you ever taken birth control pills?

44. What is the total number of years you have taken birth control pills?

45. Have you ever taken any medications to get pregnant for the treatment of infertility (such as Lupron, Clomiphene, Clomid, Serophene, Metrodin)?
yes no

46. What is the total number of years you have taken hormone replacement therapy (HRT) for menopausal symptoms?

47. What type(s) of HRTs have you taken?
48. Have you ever taken any of the medications known as selective estrogen receptor modulators (SERMS) such as Tamoxifen or Raloxifene?

49. Did you take SERMS for:

50. Did you take Diethiylstilbesterol (DES) while you were pregnant?
yes no

51. Did your mother take Dietheylstilbesterol (DES) when she was pregnant with you?
yes no

Sexual History

The next questions are about your sexual history

52. How old were you when you first had sexual intercourse?

53. How many sexual partners have you had over your lifetime?

54. Have you ever been diagnosed with a sexually transmitted disease such as herpes simplex (HSV), chlamydia, gonorrhea, syphyllis, trichomoniasis, hepatitis B, or HIV/AIDS?

55. Have you ever been diagnosed with human papillomavirus (HPV) in your genital tract?

56. Have any of your partners ever been diagnosed with a sexually transmitted disease such as herpes simplex (HSV), chlamydia, gonorrhea, syphyllis, trichomonoasis, human papillomavirus (HPV) or genital warts, hepatitis B, or HIV/AIDS?

57. If you have been sexually active, during that time, has your primary method of birth control been condoms or the diaphragm?

Family History of Cancer

58. Do you have a family history of cancer in a first-degree blood relative (mother, sister, daughter or father)?

59-91. If you answered Yes to question 58, complete the following table for your blood relatives indicated, who has had cancer. For each cancer, click on the checkbox in the column for each relative. For breast cancer you must also enter the age when your blood relative was diagnosed (you can approximate their age).

Cancer type	Mother	Sister	Sister	Daughter	Daughter	Father
Breast	Age:	Age:	Age:	Age:	Age:	Age:
Ovary
Endometrial
Colon/rectal
Other

92. Do you have any other relatives with a history of Breast,Ovarian,Endometrial or Colon/rectal cancer ?

Lifestyle Factors

The next questions are about lifestyle risk factors.

93. How many cigarettes do you smoke per day?

94. Do you usually drink more than one alcoholic drink per day?
yes no

95. Do you eat 3 or more servings of fruits or vegetables per day?
yes no

96. Do you exercise for at least 20 minutes:

Screening Practices

The next questions are about your cancer screening practices.

97. I perform breast self-exam:

98. I have a mammogram:

99. I have a yearly physical exam of breasts by a health care provider:
yes no

100. I have a PAP test:

101. I have a yearly pelvic exam by a health care provider:
yes no




Gynecologic Cancer Foundation \| 230 W. Monroe, Suite 2528 \| Chicago, IL 60606 E-mail: info@thegcf.org \| 312.578.1439 Copyright © 2002-2007, all rights reserved.