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Please supply any past history of surgery and allergy

Do you have a family history of breast cancer, including first degree relatives such as mother, blood sister and auntie?
 Yes No

Did you ever have a breast ultrasound done? If so, when?

Do you know how to do a self-examination for breast cancer?
 Yes No

Do you have a history of psychiatric or psychology problems?
 Yes No

Have you read and understood the risks associated with the surgery on the website?
 Yes No

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