How old are you?
Less than 30 years old
Between 30 and 39 years old
Between 40 and 49 years old
At least 50 years old

Have you ever had breast cancer before?
No
Yes

Has anyone in your immediate family had breast cancer?
No
Yes

How many times have you been pregnant?
More than once
Once or never

Have you ever had a breast biopsy specimen that was found to be abnormal?
No
Yes

Have you ever taken or are you now taking hormone replacement therapy?
No
Yes

Your weight is:
within 5 pounds of the healthy range
5 to 10 pounds above the healthy range
10 to 20 pounds above the healthy range
20 pounds or more above the healthy range

Do you exercise at least an hour and a half per week ?
Yes
No