RAF
3/24/99

NSABP STUDY OF TAMOXIFEN AND RALOXIFENE
RISK ASSESSMENT FORM

INSTRUCTIONS:  This form requests that you answer a few questions about your background which may relate to your risk of developing breast cancer.  The information will be evaluated and your risk of developing breast cancer will be determined.  Please fill in the information requested or place an X in the appropriate box.  Your responses will be kept strictly confidential.  You must sign and date this form.
How did you first hear about the Study of Tamoxifen and Raloxifene?
Newspaper,          
      Television or Radio		 Contacted by
      Physician or Nurse		 Referred by
      Family or Friend		 Read a Poster
      or Brochure		 Other, Specify

I. BACKGROUND INFORMATION

Name      Home Phone   
                 Last, First, M.I.                                                                                                                Area Code

Address        Work Phone   
                                                                                                                                                             Area Code

City   State     Zip/Postal Code  

Date of Birth (MM/DD/YY)                      Race or Ethnic Background (Check one box only)
                                     Caucasian/White          African-American/Black
                                                                                     Hispanic/Latina             Other, Specify


II. FAMILY HISTORY (INCLUDE ONLY YOUR BIOLOGICAL MOTHER, DAUGTER(S), AND SISTER(S))

If adopted, check here and leave blank any questions you cannot answer.

Does/Did your mother
have breast cancer?
Yes
No
Unknown



Does/Did your daughter(s)
have breast cancer?
Yes       
If Yes, number of daughters with breast cancer?
No
Not Applicable/Unknown
 Does/Did your sister(s)
have breast cancer?
Yes 
If Yes, number of sisters with breast cancer?
No
Not Applicable/Unknown

III. HISTORY OF BREAST BIOPSY
Have you ever had a breast biopsy? What were the diagnoses? (Check all that apply)
Yes  If Yes, how many?
No   Go to part IV.
 Invasive Breast Cancer                           Atypical Hyperplasia
 Ductal Carcinoma In-Situ (DCIS)           Other (Fibrocyctic Disease, etc)
 Lobular Carcinoma In-Situ (LCIS)          Unknown

IV.  REPRODUCTIVE HISTORY
How old were you
when you had your
first menstrual period?
 Years Old		 Have you ever been pregnant?
Yes
No		 If Yes
how many times have you been pregnant? Times

how many live births have you had?            Live Births

how old were you at the time                         Years Old
of your first live birth?
Have you had a
hysterectomy
(removal of
the uterus)?
Yes
No

I understand that this Risk Assessment Form will be evaluated for my risk of developing breast cancer.  If my evaluation indicates an increased breast cancer risk and I meet other study criteria, I will be offered the opportunity to participate in a research study of a medication that may prevent breast cancer.  I further understand that receiving this evaluation of my breast cancer risk does not obligate me to participate in the research.

Date:   Signature:

(STAR SUBCENTER USE ONLY)

CLINICAL                                         SUBCENTER
CENTER CODE            CODE 

(HEADQUARTERS USE ONLY)

DATE ENTERED                        CONTROL NO.
             
 Month, Date, Year

      

(Typing your name in the signature block and clicking the "Submit" button can be considered the equivalent of a signature on paper.)