Summary: Breast Pain Questionnaire
Name: Ethnicity (optional): Birthdate:
Have you ever been diagnosed with breast cancer? ____Yes ____No
Post-menopausal? ____Yes ____No
1. Have you experienced breast pain within the last three months? ___Yes ___No
If yes, please continue to fill out the rest of this survey.
2. What does your breast pain feel like?
Please check one of the four categories (none, mild, moderate, or severe) for each descriptor.
None Mild ModerateSevere