DCH Health System Screening Event

DCH Health System Breast Cancer Screening Events
Sponsored by the DCH Foundation's Breast Cancer Fund, we invite West Alabama women to free breast screenings at the DCH Breast Center.

Available Dates and Times:
- October 7, 2025 (8-12 noon)
- October 16, 2025 (12 noon-4pm)
- October 22, 2025 (12 noon-4pm)
- October 31, 2025 (8-12 noon)
Walk-Ins are welcomed; pre-registration is preferred.

Criteria for Participation:
- No personal history of breast cancer
- No health insurance
- At least 12 months since last mammogram
- Must live in the DCH service area
- For women 25-39 years old, mammograms will only be ordered if the provider recommends
Name*

First NameLast Name
Email
example@example.com
Home Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence
Date of Birth*

MonthDayYear
Please provide your date of birth.
Women ages 25-39 will receive a clinical breast examination and education. Mammograms will only be ordered if the provider recommends.
Last 4 Digits of Your Social Security Number (if applicable)
Please enter the last 4 digits of your Social Security Number (if applicable)
How did you learn about this event?

BillboardChurchDCH WebsiteNewspaperPreviously AttendedSocial Media (Facebook)The Links Incorporated
Who is your primary healthcare provider? Where do you go when you are sick?*

Do not have a healthcare providerGood Samaritan ClinicHealth DepartmentMaude Whatley ClinicUniv Medical Center (UA)Other
Are you insured?*

YesNo
You will be responsible for any deductibles associated with imaging (mammograms, ultrasounds, etc). Please bring your insurance card.
Insurance Information
Insurance Provider
Please provide the name of your insurer
Policyholder Name
Please provide the name of the policyholder; this may also be called Subscriber
Policyholder Date of Birth

MonthDayYear
Please provide the date of birth of the policyholder
Contract Number
Group Number
Do you have a medical history of any breast cancer or of ductal carcinoma in situ(DCIS) or lobular carcinoma in situ (LCIS) or have you received previous radiation therapy to the chest for treatment of Hodgkin lymphoma?*

YesNo
Do you have a mutation in either the BRCA1 or BRCA2 gene, or a diagnosis of a genetic syndrome that may be associated with elevated risk of breast cancer?*

YesNo
Age*
Race*

African American/BlackAmerican Indian or Alaskan NativeAsian AmericanCaucasian/WhiteHispana/LatinaOther
Where (country) were you born?*

USOutside the US
Where (country) were you born [Other]?
Please provide your country of birth
Have you ever had a breast biopsy with a benign (not cancer) diagnosis?*

YesNoUnknown
How many breast biopsies with a benign diagnosis have you had?

12 or more
Have you ever had a breast biopsy with atypical hyperplasia?

YesNoUnknown
How old were you at the time of your first menstrual period?*

7-1112-1314 or older
How old were you when you gave birth to your first child?*

No births< 20 years old20-24 years old25-30 years old30 or olderUnknown
How many of your FIRST degree relatives (mother, sister, daughter) have had breast cancer?*

NoneOneMore than oneUnknown
Lewis and Faye Manderson Cancer Center Breast Screening Educational Pre-Survey

Please complete. It is okay if you do not know all of the answers. Answer all questions to the best of your ability.
Do you know how to do a self-breast exam?*

YesNo
Do you do monthly self-breast exams?*

YesNo
Which of the following are risk factors for breast cancer? (please select all that apply)*

Family historyAgeObesity
Your breast cancer risk decreases as you age.*

YesNo
Early detection for breast cancer includes the following (please select all that apply):

Monthly self-breast examsRegular clinical breast examinationsMammograms every year starting at age 40
What changes in your breast would make you follow-up with a physician? (please select all that apply)

a lump or thickeningswelling, warmth, rednesspulling in of the nipplenipple discharge
Personal Data

Medical History
Are you pregnant?*

YesNo
Do you practice Breast Self-Exams regularly?*

YesNo
Do you take Estrogen or Birth Control Pills?*

YesNo
For how long?
How long have you taken estrogen or birth control pills?
Have you been diagnosed with breast cancer?*

YesNo
What year were you diagnosed with breast cancer?
What year were you diagnosed with breast cancer?
Have you ever had a mammogram and/or breast ultrasound?*

YesNo
When and where?
When and where did you have a mammogram or breast ultrasound?
Have you ever had breast surgery?*

YesNo
What year and what procedure?
When did you have breast surgery and what was the procedure?
Have you ever had radiation to either breast?*

YesNo
What year did you have radiation?
What year did you have radiation to either breast?
Do you have breast implants?*

YesNo
Do you have fibrocystic disease, mastitis or other benign breast disease?*

YesNo
Is either breast larger than the other?*

YesNo
Do you have a lump or thickness in either breast?*

YesNo
Do you have nipple discharge or an inverted nipple?*

YesNo
Do you have any concerns about your breasts or breast health?*

YesNo
What concerns do you have?
What concerns do you have about your breasts or breast health?
Please select an appointment time:*
Please arrive at your selected appointment time to complete the remaining paperwork.

Everyone must check in at the Breast Center in Outpatient Imaging at the Medical Tower.
*If you have insurance, you will be responsible for any deductibles associated with the mammogram. Please bring your insurance card.

Mammograms for women 25-39 will only be scheduled if recommended by the provider.

If you have a physician AND insurance, it would be best to contact your physician for a yearly appointment to ensure continuity of care.
Should be Empty:

DCH Health System Breast Cancer Screening Events

Insurance Information

Lewis and Faye Manderson Cancer Center Breast Screening Educational Pre-Survey

Personal Data