Number of Yes'
Do you drink less than 8 glasses of water each day?
*
Yes
No
Do you eat leafy green vegetables less than 5 times each week?
*
Yes
No
Do you exercise less than 3 days each week?
*
Yes
No
Are you more than 25 pounds overweight?
*
Yes
No
Do you wear a restrictive bra or athletic bra for more than 6 hours per day?
*
Yes
No
Do you wear an underwire bra?
*
Yes
No
Do you sleep in a bra?
*
Yes
No
Do you now or have you ever experienced pain after wearing a bra?
*
Yes
No
Do you ever notice any bluish or greenish tinge to your underarm area?
*
Yes
No
Have you a history of constipation?
*
Yes
No
Do you consume more than 1 alcoholic drink daily?
*
Yes
No
Do you smoke or have you smoked for longer than 5 years?
*
Yes
No
Have you had any piercings or tattoos done anywhere?
*
Yes
No
Do you have more than 3 fillings in your mouth or do you have any current dental infections or cavities?
*
Yes
No
Do you have a history of migraines or headaches?
*
Yes
No
Do you take Aspirin or other Tylenol Like pain reliever daily?
*
Yes
No
Do you have irregular periods?
*
Yes
No
With your period, do you have PMS or do you regularly get clots, excessive bleeding, swollen breasts or strong cramping?
*
Yes
No
Have you used hormones of any kind, such as oral contraceptives, IUD, HRT, bio-identicals or topical hormone creams?
*
Yes
No
Have you ever used breast enlargement creams or supplements?
*
Yes
No
Have you ever had fibroids, ovarian cysts or endometriosis?
*
Yes
No
Do you get swelling of the ankles?
*
Yes
No
Have you had a hysterectomy?
*
Yes
No
Do you now or have you ever had your cup size change significantly for no reason?
*
Yes
No
Do you now or have you ever had any noticeable dents or indentations one or both of the breasts?
*
Yes
No
Do you have now or have you had swelling, pain or discomfort under the arms or along the sides of the breasts?
*
Yes
No
Do you now or have you had breast tenderness or pain during sexual activity?
*
Yes
No
Do you now or have you ever have breast implants?
*
Yes
No
Have you ever breastfed?
*
Yes
No
Do you now or have you had pain or discomfort while breastfeeding?
*
Yes
No
Have you ever been diagnosed with low or hypothyroid?
*
Yes
No
Have you had a suspicious mammogram or other breast test?
*
Yes
No
Have you been diagnosed with breast cancer?
*
Yes
No
Name
*
First Name
Last Name
Email
*
example@example.com
**By providing your phone number, you agree on receiving text from our Center**
Phone Number
*
-
Area Code
Phone Number
I am ready to receive my Breast Health Score
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