Name:
Date of birth:
Current occupation: (technician, clerk, service worker, administrator, laborer in agriculture, forestry, animal husbandry and fishery, domestic worker, retiree and others)
Marital status: unmarried, married, widowed and divorced.
Height: centimeters (cm) meters (m)
Weight: kilogram (kg)
Health status:
(1) If you currently suffer from or have suffered from the following cardiovascular and cerebrovascular diseases, please tick □ before the corresponding options and you can choose more than one.
Hypertensive cerebral hemorrhage, cerebral thrombosis, coronary heart disease, pulmonary heart disease, congenital heart disease, hypertensive heart disease and other heart diseases
(2) If you are currently suffering from or have suffered from the following endocrine diseases, please tick □ before the corresponding options.
Type I diabetes mellitus type II diabetes mellitus
(3) If you are suffering from or have suffered from the following gynecological diseases, please tick "□" after the corresponding options, and multiple choices are allowed.
Cervical erosion condyloma acuminatum/genital herpes syphilis/gonorrhea chancre/venereal lymphogranuloma/inguinal granuloma/AIDS benign breast diseases (such as mammary hyperplasia/severe atypical epithelial hyperplasia) breast cancer cervical cancer uterine cancer ovarian cancer
Family genetic history:
If any member of your family has ever suffered from breast cancer, please check the corresponding option.
Have any of your mothers, sisters and daughters ever had breast cancer?
Some of your grandmothers, aunts, nieces, nieces and cousins have all had breast cancer.
Do your mother and sister have breast cancer at the same time?
Women's personal health history
(1) Your age of menarche is.
(2) Your menopausal age (if there is no menopause, please fill in the number "0") is.
(3) Your primiparity age is.
(4) Have you ever breastfed?
(5) If breast-feeding, the time of breast-feeding (more than two times can be accumulated)
(6) Is your menstrual cycle regular or irregular?
(7) Have you ever taken birth control pills (ever or now)?
(8) If you take birth control pills, your medication time is (cumulative) years.
(9) Do you take estrogen drugs?
(10) Have you ever had a mastectomy?
Physical activity and exercise
(1) Do you take part in physical exercise? Never occasionally.
(2) If you take part in sports, your current exercise frequency is less than 3 times a week and greater than or equal to 3 times a week.
(3) Your current exercise (accumulated throughout the day) is less than 30 minutes/day and greater than or equal to 30 minutes/day.
Mental and social factors
(1) Have you experienced anything unpleasant or unfortunate in the past year?
(such as unemployment, disability, divorce, death of relatives, serious illness, etc.). )
Yes or no
(2) Compared with a year ago, affected by emotional problems (such as nervousness, impatience and anxiety), what is your physical condition now?
Significantly higher than a year ago, higher than a year ago and almost lower than a year ago, significantly lower than a year ago.
(3) In the past year, due to your emotional problems (such as nervousness, impatience and anxiety), did you have the following problems at work or other activities?
If you can't finish the planned work or activities, don't work hard or take part in other activities as in the past.
Your working hours or other activities are reduced and remain the same.
Thank you. I hope it will help you and be adopted. . . .