Communicating to Illiterate Populations

Have you menstruated in the last year?
Yes No
If No:
- How old were you when your menstrual periods stopped? _____
- Did you have a hysterectomy at that time?
  Yes No Unknown
- Have you had both ovaries totally removed?
  Yes No Unknown
Have you ever taken estrogen containing drugs (e.g., birth control pills, premarin, climacteron or hormone injections)?
Yes No
If Yes, are you currently taking estrogen (or other hormones)?
Yes No
What is the total number of years you have been taking estrogen? _____
Is there a history of breast cancer among your 1st degree blood relatives (i.e., mother, full sister or daughter)?
No Yes, sister(s) Yes, mother
Yes. daughter(s) Unknown
If Yes:
- Were any of them diagnosed before age 50?
  Yes No Unknown
- Were both breasts involved for any of them?
  Yes No Unknown
Your approximate weight:
____kg or ____lbs