Screen a Participant

Risk factors, symptoms and the clinical breast examination for one participant. Everything is saved on this device as you type, so a half-finished form survives a reload.

Full Name*

Phone Number

Age (years)

Community

Weight (kg)

Height (cm)

BMI (auto)

—

BP systolic

BP diastolic

Family history of breast cancer

Previous breast lump, biopsy or surgery

Menopausal status

Age at first period (years)

Number of children

Ever breastfed

Hormonal contraception

Screened before

Practises breast self-exam

Right breast

Left breast

Axillary lymph nodes

Examination Findings

Breast Ultrasoundfirst-line for a lump, especially under 40

Mammogramfor women 40 and over

Referral

Taught breast self-examination

Other Medical History

Plan / Advice

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Screen a Participant

Participant

Vitals

Risk Factors

Symptoms

Clinical Breast Examination

Follow-up Imaging

Outcome