Title
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* Last Name

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Date of birth of person injured
(mm-dd-yyyy):

If you believe breast cancer developed as the result of a drug (i.e. Prempro), please list drug:

Date you started taking the drug (mm-yyyy):

Date you stopped taking the drug (mm-yyyy):

If diagnosed with breast cancer, please indicate details of diagnosis:
Breast cancer was hormone receptor positive for Progesterone.
Breast cancer was hormone receptor positive for Estrogen.
Lobular breast cancer was diagnosed.
Ductile breast cancer was diagnosed.

Have any family members (sisters, mother, grandmothers) been diagnosed with breast cancer?
Yes
No

If yes, please describe which family member was diagnosed and the type of cancer that was diagnosed:

Have you been genetically screened for breast cancer?
Yes
No

If you have been screened for breast cancer, please describe results:

Other Info:

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