{ title: 'The Suffolk County news. (Sayville, N.Y.) 1888-current, November 10, 1994, Page 11, Image 11', download_links: [ { link: 'http://www.loc.gov/rss/ndnp/ndnp.xml', label: 'application/rss+xml', meta: 'News about NYS Historic Newspapers - RSS Feed', }, { link: '/lccn/sn84031477/1994-11-10/ed-1/seq-11/png/', label: 'image/png', meta: '', }, { link: '/lccn/sn84031477/1994-11-10/ed-1/seq-11.pdf', label: 'application/pdf', meta: '', }, { link: '/lccn/sn84031477/1994-11-10/ed-1/seq-11/ocr.xml', label: 'application/xml', meta: '', }, { link: '/lccn/sn84031477/1994-11-10/ed-1/seq-11/ocr.txt', label: 'text/plain', meta: '', }, ] }
Image provided by: Suffolk Cooperative Library System
--~------------------------ ______________________ .- __ ---------- __ .-----'-~--~-'--->~-\-'--' it i r-------------------------------------------------------------------------------------------------------~.~ ¥ourZipCode, ___ _ BREAST HEALTH SURVEY Brookhaven Memorial Hospital Medical ;Center Women:areurged:to'C~plete~this:sUNeJ'()belppiRpGinltbe,commonf4ICtorsJeadmgtobreastcancer. Ollcoutof eightwomenonLong.lsland willdevelopbreastcanceroveralifetime . . If you are:a woman,youare at ride. Be GOOd to Yanrelf alii Your NeilhlMn. I'letuejill out tAil 811'1ft, llU,.\\\ it as SODII fllJlDssiI*. T\\\t ,,, •. I.. WIt.tis yoorpresent~ss?';J,Cuiless~ dim:cim:1Idua1?·___. ............ ___________________________ _ :2. Hew many years Dve youIived at this addmss~JtoantosafiDS lle-wa viviendo aqui? _________________________ _ 34 'What was Ihe Ci~:andStateofyoor last addresSlf.¥(.;Cuiles eRID la ciwlad y el estado de su -diJecci6n anterior? 'Ci~/Ciudad StatelEstado ________________________ _ ,4. How man, ycar.sdid YOll,live s:y0Ul'last adr.bss'fiCubtosaftos viwi6 alta? __________________________ _ 3. 'WbalisyourUteofbbtl'2/i.Fcchade:nacimiento~ ________________________________ _ .6. MothetlsmUJeanamel,ApellK1ode:solterade:su madre'? __________________ \\\\- _____________ _ 'iI~ MaiJu~sidence from ases~.!O yeam'?liJLu,gardeleSidencia principal antes de los :20 aDos'? 'CitylCiudad StatelEstado CounnyJNacl6n ______ _ .AFs20-40year.s1De los 20a«):aiios 'CitylCiudad StatelEstado Counlly/Nacioo _______ _ Ages«l;plustMisile440 rCif;)ilCiucJaid StatelEstado CounllyJNacioo _______ _ is.. What is yourmce1etJmic gJOllp7fi,CuiI es ;5U mzafFlPOcbUco? WIlite Asian Native American ----------------- African ,American Lalina Other ------------------------- 1 9. 'To tbe 'best ofyourimOwlmlc, haYe any previous ~sicJents ,of your bome had breast anr:er?Jl,Sabe nsted si ocupantes anterioresdesuQS8~ierondeQllCefmamario? Y'CS No\-- __ _ l(). Whalisyouroccupalion\'iOdies _profesi6n? ________________________________ _ 11.. ~ is the locatioo of)'ouoccupation!il,D6nde b'abaja? Cit;y/Ciuclad State/&tadQ ___ _ 12. Bow many year.shave you wOlked:at tis JoraIian?li,Cuintos dos trahajaa1li? _______________________ _ :13. Where ,did you woakbefCR?Jl.Dlinde ha~ amterionnente? City}Ciudad ____ --------------- ~~------------------------------- 14. Do you have orhave you.had InastClllCel'?I,P«la:e G ha:palleciib &Ie ancer mamario? Yes No,-_ lfyes, what was the:date!ofdiagnosis'?l& CISD af'irmativo., l,cu8ndofale descubiedo? Mmth/Mes _ Year/Afiol...-.._ 13. Has ay memberrcjfyourfanli~ t~~ daughter:., sister:) lbalIbmast caacer?ll.AigUn miembro de so familia ba.padecido de cancer mamario? Yes . No (1DIIh/h'~) , 16. Have any males ioyoorfamily hid blast Cilacetlli,Bay aJpnhombteen SIlfamllia quemvo cancerJllll1llrio? YcsNo,-, __ 1'.. Have you had .yCJiherJ3pe ofClllllCer?ltHa:pMecldo de·OII8 fmntasde CIIICeI'? Yes No,-' __ Ovarian?ll.Cmcer:c1etMrio? Otbl:t!Ji.Otm?·~(.a(y),-' __ lB. Has any member'ofyour bmsellMcl (family OIlKD-family) lad diaeranc:er?ll.Algwtes otros residenles de su casa l(famiWuesooo):suliierolldecaocer?Yes liD '1'yJJesItipos ______________________ _ 19. Have you 'ever hada'lDIIIIIJIlQgmII?Ji,. tenicJo usam-JDaJDtClau'i? Yes Nol...-.._ Jfyes., what is 8Ie'llate ofymr lastmammogtam?Ji,OIinlofae ]a 'iJlima -vcz? Montb/Mes Year/ADo 1...-.._ 26. Have you ever bad:a '!Rast bi~yl/~Ha tenido lISted unabiopsiam...na? If yes, what wereiheresu1ts?Ji,Cuiles fuemnJos resultados? Benip' :(~y.st! iCutioomain situ? Don~t know _______ _ i;Ben'ignO'?i.Ciste't.Catcinom& localizado?No:se . 21~ Have you everhadld~ ~Ji?Ii.Bam:ibidct-.stcd :radioteIajtia?Yes No,-_ 22. How old were you atYOlU'fitstmensbuatioo?Il.A twedailempezOSli menstruaci6n? _____________________ _ 23. Have you ever been lJIepant\tHa'estadoembaruada? Yes , No,-_ 24. How cold were yoo.yourMt:pregnancY~ltA 'que :edadftJcsu primer embarazo?~. ~~====== _____________ ______ 25 .. How many times have yooai'vcnbitth?ltCumtas veces haWldoa)II2'? __________________________ _ 26. Did you breast feed anyof:yOlD~hildreD?gtAmamallt6? Yes No,-_ lf~ for'9J'lO'Ximatcly Ilowmaytotal monthslfl,lJurate amntos :meses total? ______________________ _ ;271.. Have you ever used titdt ~lpiDs11i.Ha tomadoCOlltGlCepUvosorales? Ycs,-_ No\ __ For how many yeaa'211,Durmtecoanto lielQO'? _______ _ 28. Have you mlChedmenopaose?i~Da<alcaDzado :metlOpIlISia? Ycs,-_ No,-_ :29. Reason formenopause}Causade lameoopausia NaturaliNonnal ,Sugica11Cimrgica~ __ ~~-------------------------------------------------- 30. Have youeverusedmcJKtP81:lS8lltommnes '(i.~. Estrogen Rep1acement1bempy)Wl,Ha usadohormonas de menopausia, es 'decir;substiluci6nde,~trQgeDio? Yes, No, i'o~JtS/J.Cuintos aftoS? ______ --- __ --------..__- ____ _ 31. Doy()u!drlDk..,waterorhlttled water?li,Bebe:ustedaguade lapluma0 faente, oaguade botella? ____ ----------------- !ilcilcWoulil YOll be willing loanswer mooe questions to 'tla1K;ntc:OIl tis surVey? If so, please provide: (Please print) y~n~~- ____________________________________________ Tcl~bone--------- __ ------------------------- tijEsti dispuesta;a (contestar otras pregtmtas en ;esteestudil>1 Si e'Sl'i dispue~ta'escriba :su: Nnmbre\:' ._ ~ TelEfono ______ --.- __ ----------- 'Thank ,YOll for :taking the time :tocomplete this questiollllaire. Please ,mail as ;SOOBU' ~lbleJ Gracias pol'eontestareste questionario.Porfavor enlielo :10 mas pn»nto posible. RETURN THIS SURVEY TO: llroo'kbaven Milmorial Hospital Medial Cdler mreast Caneerhojed • . ICJ! HO$pitallti()od., East PatchQgUe, New York 11772 .. 'c: .~ ;F :,n '0 c ,;::, . .q :z I (It ! , I