Breast Cancer Research Questionnaire

A breast cancer research questionnaire is needed to undertake the background data check of a person diagnosed with breast cancer. This questionnaire can be analysed to suggest the best treatment for the patient and help in stopping the disease lineage.

Sample Breast Cancer Research Questionnaire:

Name:                       ______________________________

Contact number: ______________________________

Email address:            ______________________________

Age:                  ______________________________

Home Address:   _______________________________________________________

Q1. Has your family had a history of breast cancer before the age of 40?

a)   Yes

b)   No

Q2. If the answer to the above question is ‘yes’, please provide the following details of the family member who has breast cancer.

Name: _____________ Age: ________

Name:       _____________ Age: ________

Q3. Were you ever diagnosed with breast cancer?

a)   Yes

b)   No

If ‘yes’, please mention the age when you were first diagnosed with breast cancer ________

Q4. When you were diagnosed with breast cancer

a)   Your left breast was larger than your right breast

b)   Your right breast was larger than your left breast

c)   Both the breasts were of the same size

d)   I have not noticed

e)   I don’t know

Q5. Please tick the right option among the following that is applicable to you.

a)   I wear bra all day long

b)   I wear bra only during the day

c)   I do not wear a bra

d)   I wear a bra for less than 12 hours

e)   I wear a bra for slightly more than 12 hours

Q6. What is your position of sleep?

a)   Lying on your back

b)   Lying on your front

c)   Lying on the left side

d)   Lying on the right side

Q7. In which breast did you get detected of breast cancer?

a)   Left

b)   Right

Category: Research Questionnaire

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