www.check4cancer.com
Open in
urlscan Pro
2606:4700:20::681a:4be
Public Scan
Submitted URL: https://email.check4cancer.com/c/eJwkjEFu5CAQAF-Db2u1m4aBA4fVSHwgL2hjHJBtbAEjJ7-PkjnVpaoWpwgIhuimB2iYtJlwSM7O02rsg2ZQlgwgh1lrva...
Effective URL: https://www.check4cancer.com/mybreastrisk-personal/o3gn2xi2
Submission: On January 23 via api from ES — Scanned from ES
Effective URL: https://www.check4cancer.com/mybreastrisk-personal/o3gn2xi2
Submission: On January 23 via api from ES — Scanned from ES
Form analysis 8 forms found in the DOM
<form id="registerFormForm">
<div id="register-details" class="payment-billing-card wrap-block-two-column not-progressed">
<div class="payment-heading review-page-row box-heading">
<div class="heading-text">
<span data-type="logged-out">Create your account</span>
<span data-type="logged-in" class="hidden">Welcome back <span confirm-data="client_name"> </span></span>
</div>
<div class="change-my-details" data-type="register-details">Change details</div>
</div>
<div id="register-form">
<p data-type="logged-out">By creating a Check4Cancer account, we can provide you with secure access to your test results and your personalised screening programme.
<a href="#" onclick="returnToLoginChoice();return false;"><u>Click here to log in instead</u></a>.</p>
<p data-type="logged-in" class="hidden"><b>Not you?</b> <a href="#" onclick="logOutNow();return false;"><u>Click here to log out</u></a>.</p>
<div class="wrap-block-two-column">
<div class="left-column-checkout">
<div class="form-field input-text">
<label for="client[email]">Email</label>
<input autocomplete="off" type="text" id="client-email" name="client[email]" placeholder="Enter your email..." login-data="" required="required"> <!-- pattern="^([a-zA-Z0-9_\-\.]+)@([a-zA-Z0-9_\-\.]+)\.([a-zA-Z]{2,5})$"> -->
</div>
</div>
<div class="right-column-checkout">
<div class="form-field input-text twobox">
<label for="client[password]">Set your password</label>
<!-- <label for="client[card-number]" style="width:45%;margin-left:4%;">Confirm Password</label> -->
<input autocomplete="off" type="password" id="client-password" name="client[password]" placeholder="" required="required">
<!-- <input autocomplete="off" type="password" id="client-password-confirm" name="client[password_confirm]" autocomplete="new-password" style="width:45%;margin-left:4%;" placeholder="" required="required"> -->
</div>
</div>
</div>
<p>We will send a confirmation of your order to this email address</p>
<div class="wrap-block-two-column hide-on-login">
<div class="left-column-checkout form-fields">
<div class="form-field input-text threebox">
<label for="client[card-title]">Title</label>
<label for="client[client-firstname]">First Name</label>
<label for="client[lastname]">Surname</label>
<!-- <input type="text" id="client-title" name="client[client-title]" login-data="" placeholder="" required="required"> -->
<select id="client-title" name="client[client-title]" login-data="" placeholder="" required="required">
<option value="">...</option>
<option value="Ms">Ms</option>
<option value="Mr">Mr</option>
<option value="Mrs">Mrs</option>
<option value="Miss">Miss</option>
<option value="Dr">Dr</option>
<option value="Prof">Prof</option>
<option value="Lady">Lady</option>
<option value="Sir">Sir</option>
<option value="Mx">Mx</option>
</select>
<input type="text" id="client-firstname" name="client[firstname]" login-data="" placeholder="" required="required">
<input type="text" id="client-lastname" name="client[lastname]" login-data="" placeholder="" required="required">
</div>
</div>
<div class="right-column-checkout">
</div>
</div>
<div class="hidden">
<p><span class="medium-weight">Date of Birth</span><br>We require your Date of Birth to check this is appropriate</p>
<div>
<div class="form-field input-text threebox">
<label for="client[dob-day]">Day</label>
<label for="client[dob-month]">Month</label>
<label for="client[dob-year]">Year</label>
<input type="text" maxlength="2" id="client-dob-day" name="client[dob-day]" login-data="" placeholder="" required="required">
<input type="text" maxlength="2" id="client-dob-month" name="client[dob-month]" login-data="" placeholder="" required="required">
<input type="text" maxlength="4" id="client-dob-year" name="client[dob-year]" login-data="" placeholder="" required="required">
</div>
</div>
</div>
<div class="wrap-block-two-column">
<div class="left-column-checkout">
<div class="form-field input-text">
<label for="client[mobile]">Mobile</label>
<input autocomplete="off" type="text" id="client-mobile" name="client[mobile]" placeholder="Enter your mobile number..." login-data="" required="required">
</div>
</div>
</div>
<!--
<div class="form-field input-text">
<p><span class="medium-weight">Sex</span><br>Some of our services are sex specific or contain sex specific recommendations. For further information <a href="/sex-and-gender-faq" target="_blank"><u>read our sex and gender FAQ</u></a>.</p>
<select id="client-sex" name="client[sex]" required="required">
<option value="">Please select...</option>
<option value="M">Male</option>
<option value="F">Female</option>
</select>
</div>
-->
<div class="form-fields">
<div class="form-field input-checkbox">
<input type="checkbox" id="client-consent1" name="client[consent1]" required="required">
<label for="client-consent1">I consent to the storage and processing of my <a href="/privacy-and-cookies-policy" target="_blank" data-title="Click to view our Privacy and Cookies Policy">personal and medical data</a> and to
Check4Cancer communicating with me in relation to this service? *</label>
<div class="error-message-wrap"><span class="error-message">We require this consent in order to provide the service to you. Please call <a href="tel:+448000856663" class="telTrack">0800 085 6663</a> if you have any
concerns.</span></div>
</div>
<div class="form-field input-checkbox" id="symptom-consent">
<input type="checkbox" id="client-consent2" name="client[consent2]" required="required">
<label for="client-consent2">I do not have <a href="#" id="symptoms-text" onclick="return false;" data-title="">symptoms</a> *</label>
<div class="error-message-wrap"><span class="error-message">Screening services are only suitable for use if you are non-symptomatic.</span></div>
</div>
<div class="form-field input-checkbox" id="prosandcons-consent">
<input type="checkbox" id="client-consent3" name="client[consent3]" required="required">
<label for="client-consent3">I understand the
<a href="#" onclick="makeModal('pros-and-cons', true);return false;" data-modal="pros-and-cons" data-title="Click to view the Pros and Cons of Screening in a popup window.">pros and cons of screening</a> *</label>
<div class="error-message-wrap"><span class="error-message">It is important that you have read and understand these prior to purchasing and using our services.</span></div>
</div>
<div class="form-field input-checkbox">
<input type="checkbox" id="client-consent4" name="client[consent4]">
<label for="client-consent4">I would like to be updated with Check4Cancer news, cancer advice and awareness and offers.</label>
<div class="error-message-wrap"><span class="error-message"></span></div>
</div>
<!-- <p>Please review our <a href="/" target="_blank">Privacy Policy</a> which gives you full details on your personal data and your rights. Please call us on <a href="tel:+448000856663">0800 085 6663</a> if you have any questions.</p> -->
<p>* Indicates mandatory</p>
<div class="form-fields">
<div class="form-field input-text right">
<input id="submit-registration" class="solid" type="submit" value="Continue">
<div id="register-response-error" class="error-message-wrap">
<span class="error-message"></span>
</div>
</div>
</div>
</div>
</div>
</div>
<input type="hidden" id="client-id" name="client[id]" value="">
<input type="hidden" id="client-corporate-id" name="client[corporate_id]" value="375">
<input type="hidden" id="client-corporate-shortcode" name="client[corporate_shortcode]" value="Santander">
<input type="hidden" id="client-pbc" name="client[pbc_id]" value="120506">
</form><form id="card-form" class="form-validate">
<div class="payment-billing-card">
<div class="payment-billing">
<div class="payment-heading">Payment Info</div>
<div>
<div class="form-fields">
<div class="form-field input-text">
<label for="payment[card-holder]">Cardholder name</label>
<input type="text" id="card-holder" name="payment[card_name]" placeholder="Name as it appears on card" required="required">
</div>
<div class="form-field input-text twobox">
<label for="payment[postcode]">UK Postcode</label>
<input type="text" id="card-postcode" name="payment[billing_postcode]" placeholder="Postcode" required="required" autocomplete="pca-override">
<!-- <button class="solid" type="button">Find address</button> -->
</div>
<div id="billingAddressFullToggle" class="form-field input-text">
<a href="#" onclick="jQuery('#billingAddressFull').removeClass('hidden');jQuery('#billingAddressFullToggle').addClass('hidden');return false;">Enter address manually</a>
</div>
<div id="billingAddressFull" class="hidden">
<div class="form-field input-text">
<label for="payment[card-address1]">Address Line 1 *</label>
<input type="text" id="card-address1" name="payment[billing_address1]" placeholder="" required="required" autocomplete="pca-override">
</div>
<div class="form-field input-text">
<label for="payment[card-address2]">Address Line 2</label>
<input type="text" id="card-address2" name="payment[billing_address2]" placeholder="">
</div>
<div class="form-field input-text">
<label for="payment[card-city]">City *</label>
<input type="text" id="card-city" name="payment[billing_city]" placeholder="" required="required">
</div>
<div class="form-field input-text">
<label for="payment[card-country-id]">Country *</label>
<select type="text" id="card-country-id" name="payment[billing_country_id]" style="width:100%;" required="required">
<option value="231">United Kingdom</option>
<option value="231">We only opperate within the UK</option>
</select>
</div>
<!-- <input type="hidden" name="payment[billing_country_id]" value="231" /> -->
<input type="hidden" name="payment[billing_country_name]" value="United Kingdom">
</div>
<input id="card-type" type="hidden" name="payment[card_type]" value="">
<input id="basket-name" type="hidden" name="basket[name]" value="MyBreastRisk">
<input id="basket-amount" type="hidden" name="basket[amount]" value="281">
<input id="basket-appoint-type" type="hidden" name="basket[appoint_type]" value="consultantservices">
<input id="basket-appoint-value" type="hidden" name="basket[appoint_value]" value="consult_mybreastrisk">
<input type="hidden" name="basket[type]" value="payment">
</div>
</div>
</div>
<div class="payment-card">
<div class="payment-heading">Debit/Credit Card Info</div>
<div>
<div class="form-fields">
<div class="form-field input-text">
<label for="payment[card-number]">Cardholder number</label>
<input type="text" id="card-number" name="payment[card_number]" placeholder="0000 0000 0000 0000" required="required">
</div>
</div>
<div class="form-field input-text threebox">
<label for="payment[card-expiry-month]">Expiry Date</label>
<label for="payment[card-expiry-year]"></label>
<label for="payment[card-cvv]">CVV</label>
<!--
<input type="text" id="card-expiry-month" name="payment[card_expire_date_month]" placeholder="MM" required="required">
<input type="text" id="card-expiry-year" name="payment[card_expire_date_year]" placeholder="YY" required="required">
-->
<select id="card-expiry-month" name="payment[card_expire_date_month]" placeholder="MM" required="required">
<option value="01">01</option>
<option value="02">02</option>
<option value="03">03</option>
<option value="04">04</option>
<option value="05">05</option>
<option value="06">06</option>
<option value="07">07</option>
<option value="08">08</option>
<option value="09">09</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select>
<select id="card-expiry-year" name="payment[card_expire_date_year]" placeholder="YY" required="required">
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
<option value="32">32</option>
<option value="33">33</option>
<option value="34">34</option>
<option value="35">35</option>
<option value="36">36</option>
</select>
<input type="text" id="card-cvv" name="payment[card_security]" placeholder="..." required="required">
</div>
<div class="form-field input-text twobox right">
<input id="submit-card" class="solid" type="submit" value="Continue">
<div id="card-response-error" class="error-message-wrap">
<span class="error-message"></span>
</div>
</div>
</div>
</div>
</div>
</form><form id="deliveryForm">
<div id="delivery-details" class="payment-billing-card wrap-block-two-column not-progressed">
<div class="payment-heading review-page-row box-heading">
<div class="heading-text">Delivery details</div>
<div class="change-my-details" data-type="delivery-details">Change details</div>
</div>
<div>
<p id="delivery-details-sentence">This is where your test kit and any printed letter will be sent.</p>
<div class="form-fields hidden">
<div class="form-field input-checkbox">
<input type="checkbox" id="different-delivery" name="client[different-delivery]">
<label for="different-delivery">Uncheck to add a different delivery address <!--Check this box to use the same delivery and billing address--></label>
</div>
</div>
<div id="different-delivery-address" class="">
<div class="form-field input-text twobox">
<label for="delivery[postcode]">UK Postcode</label>
<input type="text" id="delivery-postcode" name="delivery[postcode]" placeholder="Postcode" autocomplete="pca-override">
<!-- <button class="solid" type="button">Find address</button> -->
</div>
<div class="form-field input-text">
<label for="delivery[address1]">Address Line 1</label>
<input type="text" id="delivery-address1" name="delivery[address1]" placeholder="" autocomplete="pca-override">
</div>
<div class="form-field input-text">
<label for="delivery[address2]">Address Line 2</label>
<input type="text" id="delivery-address2" name="delivery[address2]" placeholder="">
</div>
<div class="form-field input-text">
<label for="delivery[city]">City</label>
<input type="text" id="delivery-city" name="delivery[city]" placeholder="">
</div>
<div class="form-field input-text">
<label for="delivery[country-id]">Country *</label>
<select type="text" id="delivery-country-id" name="delivery[country-id]" style="width:100%;" required="required">
<option value="231">United Kingdom</option>
<option value="231">We only opperate within the UK</option>
</select>
</div>
<!-- <input type="hidden" name="delivery[country-id]" value="231" /> -->
<input type="hidden" name="delivery[country-name]" value="United Kingdom">
</div>
<button id="delivery-to-confirm" class="solid" type="button">Continue</button>
</div>
</div>
</form><form id="complete-form">
<div class="order-summary-item">
<img class="order-summary-item-image jch-lazyload" src="/images/kit-photopgraphy/MyBreastRisk_Web_2.jpg" alt="" data-src="/">
<div class="order-summary-item-info">
<div class="order-summary-item-title-price">
<span class="order-summary-item-title">MyBreastRisk</span>
<span class="order-summary-item-price pound-price hidden">281</span>
</div>
<div>
<h3>Thank you for choosing MyBreastRisk, our at-home DNA saliva sample collection kit to determine your personal risk of developing breast cancer. </h3>
<ul class="checklist blue-text pink-ticks">
<li>We provide you with a personalised screening programme. </li>
<li>Results from your DNA test and questionnaire results will give you a 'Lifetime Risk Score'. </li>
</ul>
</div>
<div class="order-summary-item-note delivery-van ">
<strong>Free recorded</strong> delivery in discrete packaging within two working days.
</div>
</div>
</div>
<div class="wrap-block-two-column">
<div class="left-column-checkout">
<div class="payment-heading review-page-row box-heading">
<div class="heading-text">Your accounts details</div>
<div class="change-my-details" data-type="register-details">Change details</div>
</div>
<div class="review-page-billing-info review-page-row">
<div class="review-page-column">
<div class="review-page-personal-details-text"> Name: <span confirm-data="client_name">{client_name}</span><br> Date of birth: <span confirm-data="client_dob_day">{client_dob_day}</span> <span
confirm-data="client_dob_month">{client_dob_month}</span> <span confirm-data="client_dob_year">{client_dob_year}</span><br>
<span class="hidden">Sex: <span confirm-data="client_sex">{client_sex}</span><br></span> Email: <span confirm-data="client_email">{client_email}</span>
</div>
</div>
</div>
</div>
<div class="right-column-checkout">
<div class="payment-heading review-page-row box-heading">
<div class="heading-text">Delivery details</div>
<div class="change-my-details" data-type="delivery-details">Change details</div>
</div>
<div class="review-page-billing-info review-page-row">
<div class="review-page-column">
<div class="review-page-personal-details-text">
<span id="applepayaddress"></span>
<span confirm-data="client_address">{client_address}</span>
</div>
</div>
</div>
</div>
</div>
<div class="">
<div class="">
<div class="payment-billing-card">
<div style="width:100%;">
<div class="payment-heading review-page-row box-heading">
<div class="heading-text">Payment details</div>
<div class="change-my-details" data-type="register-details">Change details</div>
</div>
<div class="wrap-block-two-column">
<div class="review-page-billing-info-text left-column-checkout">
<div class="heading-text">Payment name and address</div>
<span confirm-data="billing_name">{billing_name}</span><br>
<span confirm-data="billing_address">{billing_address}</span>
</div>
<div class="review-page-payment-info review-page-row payment-method right-column-checkout" data-method="paypal">
<div class="review-page-column">
<span class="review-page-column-label"><span confirm-data="payment_method">PayPal</span></span>
</div>
</div>
<div class="review-page-payment-info review-page-row payment-method right-column-checkout" data-method="applepay">
<div class="review-page-column">
<span class="review-page-column-label"><span confirm-data="payment_method">ApplePay</span></span>
</div>
</div>
<div class="review-page-payment-info review-page-row payment-method right-column-checkout" data-method="card">
<div class="review-page-column">
<span class="review-page-column-label"><span confirm-data="payment_method">Card</span></span>
</div>
<div class="review-page-column">
<div class="review-page-payment-info-text">
<span confirm-data="billing_name">{billing_name}</span><br>
<span confirm-data="card_number">{card_number}</span><br> Expiry date: <span confirm-data="card_expire_month">{card_expire_month}</span>/<span confirm-data="card_expire_year">{card_expire_year}</span>
</div>
</div>
</div>
<div class="review-page-payment-info review-page-row payment-method right-column-checkout" data-method="none">
<div class="review-page-column">
<span class="review-page-column-label"><span confirm-data="payment_method">Plan</span></span>
</div>
<div class="review-page-column">
<div class="review-page-payment-info-text">
<span id="nopaymessage"></span>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="right-column-checkout hidden">
<div class="payment-heading review-page-row box-heading">
<div class="heading-text">Appointment details</div>
<!-- <div class="change-my-details" data-type="register-details">Change details</div> -->
</div>
<div class="clinics-locator-current-location-block">
<div class="clinics-locator-current-location-block-others" style="margin-top:0;">
<span class="service" data-appoint="service"><!-- service --></span><br>
<a class="marker" data-appoint="clinic" href="/<!-- clinic_url -->" target="_blank"><!-- clinic --></a><br>
<span class="address" data-appoint="address"><!-- address --></span><br>
<span class="calendar" data-appoint="calendar"><!-- date --></span><br>
<span class="clock" data-appoint="clock"><!-- time --></span><br>
</div>
</div>
</div>
</div>
<div class="review-page-row buttons">
<div class="form-fields">
<div class="form-field button">
<button id="place-order" class="solid" type="button">Place your order</button>
<div id="order-response-error" class="error-message-wrap">
<span class="error-message"></span>
</div>
</div>
</div>
</div>
<input id="order-payment-method" type="hidden" name="order[payment-method]" value="none">
<input id="order-payment-reference" type="hidden" name="order[payment-reference]" value="">
<input id="order-payment-id" type="hidden" name="order[payment-id]" value="">
<input id="order-age-min" type="hidden" name="order[void]" value="30">
<input id="order-age-msg" type="hidden" name="order[void]" value="">
</form><form class="frame-form">
<div class="frame-form-header">
<div class="frame-form-title"> Risk Questions </div>
<div class="frame-form-progress">
<div class="frame-form-progress-counter">
<span class="frame-form-answered-count">1</span> of <span class="frame-form-total-count">37</span>
</div>
<div class="frame-form-progress-answered-label">Answered</div>
</div>
</div>
<div id="frame-form-content" class="frame-form-content">
<div class="frame-form-desc">
</div>
<ol id="frame-form-questions" class="frame-form-questions">
<li id="qid6" class="frame-form-question" data-remove-if="||">
<div class="frame-form-question-text" data-num="1">Weight</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q0" name="client[d_weight]" require="">
<option value="">Please select...</option>
<option value="38.1">6st / 38.1kg</option>
<option value="39.5">6st 3 lbs / 39.5kg</option>
<option value="41.3">6st 7 lbs / 41.3kg</option>
<option value="42.6">6st 10 lbs / 42.6kg</option>
<option value="44.0">6st 13 lbs / 44.0kg</option>
<option value="45.4">7st 2 lbs / 45.4kg</option>
<option value="47.2">7st 6 lbs / 47.2kg</option>
<option value="48.5">7st 9 lbs / 48.5kg</option>
<option value="49.9">7st 12 lbs / 49.9kg</option>
<option value="51.7">8st 2 lbs / 51.7kg</option>
<option value="53.1">8st 5 lbs / 53.1kg</option>
<option value="54.4">8st 8 lbs / 54.4kg</option>
<option value="56.2">8st 12 lbs / 56.2kg</option>
<option value="57.6">9st 1 lbs / 57.6kg</option>
<option value="59.0">9st 4 lbs / 59.0kg</option>
<option value="60.3">9st 7 lbs / 60.3kg</option>
<option value="62.1">9st 11 lbs / 62.1kg</option>
<option value="63.5">10st / 63.5kg</option>
<option value="" selected="selected">Please select...</option>
<option value="65.3">10st 4 lbs / 65.3kg</option>
<option value="67.1">10st 8 lbs / 67.1kg</option>
<option value="69.4">10st 13 lbs / 69.4kg</option>
<option value="71.7">11st 4 lbs / 71.7kg</option>
<option value="73.9">11st 9 lbs / 73.9kg</option>
<option value="75.7">11st 13 lbs / 75.7kg</option>
<option value="78.0">12st 4 lbs / 78.0kg</option>
<option value="80.3">12st 9 lbs / 80.3kg</option>
<option value="82.6">13st / 82.6kg</option>
<option value="84.4">13st 4 lbs / 84.4kg</option>
<option value="86.6">13st 9 lbs / 86.6kg</option>
<option value="88.9">14st / 88.9kg</option>
<option value="90.7">14st 4 lbs / 90.7kg</option>
<option value="92.9">14st 9 lbs / 92.9kg</option>
<option value="95.2">15st / 95.2kg</option>
<option value="97.0">15st 4 lbs / 97.0kg</option>
<option value="99.3">15st 9 lbs / 99.3kg</option>
<option value="101.6">16st / 101.6kg</option>
<option value="107.9">17st / 107.9kg</option>
<option value="114.3">18st / 114.3kg</option>
<option value="120.6">19st / 120.6kg</option>
<option value="127">20st / 127kg</option>
<option value="133.3">21st / 133.3kg</option>
<option value="139.7">22st / 139.7kg</option>
<option value="146">23st / 146kg</option>
<option value="152.4">24st / 152.4kg</option>
<option value="158.7">25st / 158.7kg</option>
<option value="165.1">26st / 165.1kg</option>
<option value="171.4">27st / 171.4kg</option>
<option value="177.8">28st / 177.8kg</option>
<option value="184.1">29st / 184.1kg</option>
<option value="190.5">30st / 190.5kg</option>
<option value="195">30st 10 lbs / 195kg</option>
<option value="200">31st 7 lbs / 200kg</option>
<option value="205">32st 4 lbs / 205kg</option>
<option value="210">33st 1 lbs / 210kg</option>
<option value="215">33st 12 lbs / 215kg</option>
<option value="220">34st 10 lbs / 220kg</option>
<option value="225">35st 7 lbs / 225kg</option>
<option value="230">36st 4 lbs / 230kg</option>
<option value="235">37st 1 lbs / 235kg</option>
<option value="240">37st 12 lbs / 240kg</option>
<option value="245">38st 9 lbs / 245kg</option>
<option value="250">39st 6 lbs / 250kg</option>
</select></div>
</div>
</div>
</li>
<li id="qid7" class="frame-form-question" data-remove-if="||">
<div class="frame-form-question-text" data-num="2">Height</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q1" name="client[d_height]" require="">
<option value="">Please select...</option>
<option value="91.5">3' / 91.5cm</option>
<option value="94">3' 1 / 94cm</option>
<option value="96.5">3' 2 / 96.5cm</option>
<option value="99">3' 3 / 99cm</option>
<option value="101.5">3' 4 / 101.5cm</option>
<option value="104">3' 5 / 104cm</option>
<option value="106.5">3' 6 / 106.5cm</option>
<option value="109">3' 7 / 109cm</option>
<option value="111.5">3' 8 / 111.5cm</option>
<option value="114">3' 9 / 114cm</option>
<option value="116.5">3' 10 / 116.5cm</option>
<option value="119">3'11" / 119cm</option>
<option value="121.5">4' / 121.5cm</option>
<option value="124">4' 1 / 124cm</option>
<option value="127">4' 2 / 127cm</option>
<option value="129.5">4' 3 / 129.5cm</option>
<option value="132">4' 4 / 132cm</option>
<option value="134.5">4' 5 / 134.5cm</option>
<option value="137">4' 6 / 137cm</option>
<option value="139.5">4' 7 / 139.5cm</option>
<option value="142">4' 8 / 142cm</option>
<option value="144.5">4' 9 / 144.5cm</option>
<option value="147">4' 10 / 147cm</option>
<option value="150">4' 11 / 150cm</option>
<option value="152.5">5' / 152.5cm</option>
<option value="" selected="selected">Please select...</option>
<option value="155">5' 1 / 155cm</option>
<option value="157.5">5' 2 / 157.5cm</option>
<option value="160">5' 3 / 160cm</option>
<option value="162.5">5' 4 / 162.5cm</option>
<option value="165">5' 5 / 165cm</option>
<option value="167.5">5' 6 / 167.5cm</option>
<option value="170">5' 7 / 170cm</option>
<option value="172.5">5' 8 / 172.5cm</option>
<option value="175">5' 9 / 175cm</option>
<option value="177.5">5' 10 / 177.5cm</option>
<option value="180">5' 11 / 180cm</option>
<option value="183">6' / 183cm</option>
<option value="185.5">6' 1 / 185.5cm</option>
<option value="188">6' 2 / 188cm</option>
<option value="190.5">6' 3 / 190.5cm</option>
<option value="193">6' 4 / 193cm</option>
<option value="195.5">6' 5 / 195.5cm</option>
<option value="198">6' 6 / 198cm</option>
<option value="200.5">6' 7 / 200.5cm</option>
<option value="203">6' 8 / 203cm</option>
<option value="205.5">6' 9 / 205.5cm</option>
<option value="208">6' 10 / 208cm</option>
<option value="210.5">6' 11 / 210.5cm</option>
<option value="213">7' / 213cm</option>
<option value="216">7' 1 / 216cm</option>
<option value="218.5">7' 2 / 218.5cm</option>
<option value="221">7' 3 / 221cm</option>
<option value="223.5">7' 4 / 223.5cm</option>
<option value="226">7' 5 / 226cm</option>
<option value="228.5">7' 6 / 228.5cm</option>
<option value="231">7' 7 / 231cm</option>
<option value="233.5">7' 8 / 233.5cm</option>
<option value="236">7' 9 / 236cm</option>
<option value="238.5">7' 10 / 238.5cm</option>
<option value="241">7' 11 / 241cm</option>
<option value="243.5">8' / 243.5cm</option>
</select></div>
</div>
</div>
</li>
<li id="qid118" class="frame-form-question" data-remove-if="">
<div class="frame-form-question-text" data-num="3">Have you been previously diagnosed with breast cancer?</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q2-0" name="clientextra[118]" value="-1" onchange="checkIfRemove('118', jQuery(this).val(), jQuery(this).attr('data-trigger-message'));"
data-trigger-message="undefined"><label for="aform-frame-q2-0">No</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q2-1" name="clientextra[118]" value="1" onchange="checkIfRemove('118', jQuery(this).val(), jQuery(this).attr('data-trigger-message'));"
data-trigger-message="undefined"><label for="aform-frame-q2-1">Yes</label></div>
</div>
</div>
</li>
<li id="qid115" class="frame-form-question" data-remove-if="|118:1|">
<div class="frame-form-question-text" data-num="4">Is there any history of breast or ovarian cancer with any blood relative in your immediate or extended family?</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q3-0" name="clientextra[115]" value="-1"><label for="aform-frame-q3-0">No</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q3-1" name="clientextra[115]" value="16"><label for="aform-frame-q3-1">Yes</label></div>
</div>
</div>
</li>
<li id="qid47" class="frame-form-question" data-remove-if="||">
<div class="frame-form-question-text" data-num="5">Previous breast cancer?</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q4-0" name="clientextra[47]" value="0"><label for="aform-frame-q4-0">No</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q4-1" name="clientextra[47]" value="1"><label for="aform-frame-q4-1">Yes</label></div>
</div>
</div>
</li>
<li id="qid48" class="frame-form-question" data-remove-if="|118:1|">
<div class="frame-form-question-text" data-num="6">How old were you when you had your first period?</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q5" name="clientextra[48]" require="">
<option value="">Please select...</option>
<option value="0">Never menstruated</option>
<option value="8">8yrs</option>
<option value="9">9yrs</option>
<option value="10">10yrs</option>
<option value="11">11yrs</option>
<option value="12">12yrs</option>
<option value="13">13yrs</option>
<option value="14">14yrs</option>
<option value="15">15yrs</option>
<option value="16">16yrs</option>
<option value="17">17yrs</option>
<option value="18">18yrs</option>
<option value="19">19yrs</option>
<option value="20">20yrs</option>
</select></div>
</div>
</div>
</li>
<li id="qid49" class="frame-form-question" data-remove-if="|118:1|">
<div class="frame-form-question-text" data-num="7">Are you of Ashkenazi Jewish Ancestry?</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q6-0" name="clientextra[49]" value="-1"><label for="aform-frame-q6-0">No</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q6-1" name="clientextra[49]" value="1"><label for="aform-frame-q6-1">Yes</label></div>
</div>
</div>
</li>
<li id="qid50" class="frame-form-question" data-remove-if="|118:1|">
<div class="frame-form-question-text" data-num="8">Do you have any children?</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q7-0" name="clientextra[50]" value="-1"><label for="aform-frame-q7-0">No</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q7-1" name="clientextra[50]" value="1"><label for="aform-frame-q7-1">Yes</label></div>
</div>
</div>
</li>
<li id="qid51" class="frame-form-question hidden" data-related="50" data-related-answers="1" data-remove-if="|118:1|">
<div class="frame-form-question-text" data-num="..">What age did you give birth to your first child?</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q8" name="clientextra[51]">
<option value="">Please select...</option>
<option value="0">No children</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
<option value="32">32</option>
<option value="33">33</option>
<option value="34">34</option>
<option value="35">35</option>
<option value="36">36</option>
<option value="37">37</option>
<option value="38">38</option>
<option value="39">39</option>
<option value="40">40</option>
<option value="41">41</option>
<option value="42">42</option>
<option value="43">43</option>
<option value="44">44</option>
<option value="45">45</option>
<option value="46">46</option>
<option value="47">47</option>
<option value="48">48</option>
<option value="49">49</option>
<option value="50">50</option>
</select></div>
</div>
</div>
</li>
<li id="qid52" class="frame-form-question" data-remove-if="|118:1|">
<div class="frame-form-question-text" data-num="9">Have you been through the menopause?</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q9-0" name="clientextra[52]" value="2"><label for="aform-frame-q9-0">Currently perimenopausal</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q9-1" name="clientextra[52]" value="0"><label for="aform-frame-q9-1">No</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q9-2" name="clientextra[52]" value="1"><label for="aform-frame-q9-2">Yes</label></div>
</div>
</div>
</li>
<li id="qid53" class="frame-form-question hidden" data-related="52" data-related-answers="1" data-remove-if="|118:1|">
<div class="frame-form-question-text" data-num="..">If yes, how old were you at menopause?</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q10" name="clientextra[53]">
<option value="">Please select...</option>
<option value="0">Not applicable</option>
<option value="30">30</option>
<option value="31">31</option>
<option value="32">32</option>
<option value="33">33</option>
<option value="34">34</option>
<option value="35">35</option>
<option value="36">36</option>
<option value="37">37</option>
<option value="38">38</option>
<option value="39">39</option>
<option value="40">40</option>
<option value="41">41</option>
<option value="42">42</option>
<option value="43">43</option>
<option value="44">44</option>
<option value="45">45</option>
<option value="46">46</option>
<option value="47">47</option>
<option value="48">48</option>
<option value="49">49</option>
<option value="50">50</option>
<option value="51">51</option>
<option value="52">52</option>
<option value="53">53</option>
<option value="54">54</option>
<option value="55">55</option>
<option value="56">56</option>
<option value="57">57</option>
<option value="58">58</option>
<option value="59">59</option>
<option value="60">60</option>
<option value="61">61</option>
<option value="62">62</option>
<option value="63">63</option>
<option value="64">64</option>
<option value="65">65</option>
<option value="66">66</option>
<option value="67">67</option>
<option value="68">68</option>
<option value="69">69</option>
<option value="70">70</option>
</select></div>
</div>
</div>
</li>
<li id="qid54" class="frame-form-question" data-remove-if="|118:1|">
<div class="frame-form-question-text" data-num="10">Do you or have you ever used HRT?</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q11-0" name="clientextra[54]" value="-1"><label for="aform-frame-q11-0">No</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q11-1" name="clientextra[54]" value="1"><label for="aform-frame-q11-1">Yes</label></div>
</div>
</div>
</li>
<li id="qid55" class="frame-form-question hidden" data-related="54" data-related-answers="1" data-remove-if="|118:1|">
<div class="frame-form-question-text" data-num="..">Started using (mm/yyyy)</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><input type="text" id="aform-frame-q12" name="clientextra[55]" value="" placeholder="mm/yyyy"></div>
</div>
</div>
</li>
<li id="qid56" class="frame-form-question hidden" data-related="54" data-related-answers="1" data-remove-if="|118:1|">
<div class="frame-form-question-text" data-num="..">Date last used (mm/yyyy)</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><input type="text" id="aform-frame-q13" name="clientextra[56]" value="" placeholder="mm/yyyy"></div>
</div>
</div>
</li>
<li id="qid57" class="frame-form-question hidden" data-related="54" data-related-answers="1" data-remove-if="|118:1|">
<div class="frame-form-question-text" data-num="..">What type?</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q14-0" name="clientextra[57]" value="0"><label for="aform-frame-q14-0">Unknown</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q14-1" name="clientextra[57]" value="1"><label for="aform-frame-q14-1">Oestrogen only</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q14-2" name="clientextra[57]" value="2"><label for="aform-frame-q14-2">Combined</label></div>
</div>
</div>
</li>
<li id="qid58" class="frame-form-question" data-remove-if="|118:1|">
<div class="frame-form-question-text" data-num="11">Have you had a breast biopsy in the past?</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q15-0" name="clientextra[58]" value="0"><label for="aform-frame-q15-0">No</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q15-1" name="clientextra[58]" value="1"><label for="aform-frame-q15-1">Yes</label></div>
</div>
</div>
</li>
<li id="qid59" class="frame-form-question hidden" data-related="58" data-related-answers="1" data-remove-if="|118:1|">
<div class="frame-form-question-text" data-num="..">Were any of the following identified?</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q16-0" name="clientextra[59]" value="0"><label for="aform-frame-q16-0">None</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q16-1" name="clientextra[59]" value="1"><label for="aform-frame-q16-1">Hyperplasia</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q16-2" name="clientextra[59]" value="2"><label for="aform-frame-q16-2">Atypical hyperplasia</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q16-3" name="clientextra[59]" value="3"><label for="aform-frame-q16-3">LCIS (pre-cancerous cells)</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q16-4" name="clientextra[59]" value="4"><label for="aform-frame-q16-4">Unknown</label></div>
</div>
</div>
</li>
<li id="qid60" class="frame-form-question" data-remove-if="|118:1|">
<div class="frame-form-question-text" data-num="12">Have you ever had ovarian cancer?</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q17-0" name="clientextra[60]" value="0"><label for="aform-frame-q17-0">No</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q17-1" name="clientextra[60]" value="1"><label for="aform-frame-q17-1">Yes</label></div>
</div>
</div>
</li>
<li id="qid61" class="frame-form-question hidden" data-related="60" data-related-answers="1" data-remove-if="|118:1|">
<div class="frame-form-question-text" data-num="..">If yes, at what age?</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q18" name="clientextra[61]">
<option value="">Please select...</option>
<option value="0">Not applicable</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="31">31</option>
<option value="32">32</option>
<option value="33">33</option>
<option value="34">34</option>
<option value="35">35</option>
<option value="36">36</option>
<option value="37">37</option>
<option value="38">38</option>
<option value="39">39</option>
<option value="40">40</option>
<option value="41">41</option>
<option value="42">42</option>
<option value="43">43</option>
<option value="44">44</option>
<option value="45">45</option>
<option value="46">46</option>
<option value="47">47</option>
<option value="48">48</option>
<option value="49">49</option>
<option value="50">50</option>
<option value="51">51</option>
<option value="52">52</option>
<option value="53">53</option>
<option value="54">54</option>
<option value="55">55</option>
<option value="56">56</option>
<option value="57">57</option>
<option value="58">58</option>
<option value="59">59</option>
<option value="60">60</option>
<option value="61">61</option>
<option value="62">62</option>
<option value="63">63</option>
<option value="64">64</option>
<option value="65">65</option>
<option value="66">66</option>
<option value="67">67</option>
<option value="68">68</option>
<option value="69">69</option>
<option value="70">70</option>
</select></div>
</div>
</div>
</li>
<li id="qid62" class="frame-form-question" data-remove-if="|118:1|">
<div class="frame-form-question-text" data-num="13">Have you been tested for BRCA1 and/or BRCA2 mutations</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q19" name="clientextra[62]" require="">
<option value="">Please select...</option>
<option value="0">Not tested</option>
<option value="1">I do not know</option>
<option value="2">Negative</option>
<option value="3">BRCA 1 Positive</option>
<option value="4">BRCA 2 Positive</option>
</select></div>
</div>
</div>
</li>
<li id="qid63" class="frame-form-question just-text" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="">
<p><b>Your mother</b><br>Please answer the following questions regarding your Mother:</p>
</div>
</li>
<li id="qid64" class="frame-form-question" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="15">Current age or age died</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q21" name="clientextra[64]" require="">
<option value="">Please select...</option>
<option value="18">18 </option>
<option value="19">19 </option>
<option value="20">20 </option>
<option value="21">21 </option>
<option value="22">22 </option>
<option value="23">23 </option>
<option value="24">24 </option>
<option value="25">25 </option>
<option value="26">26 </option>
<option value="27">27 </option>
<option value="28">28 </option>
<option value="29">29 </option>
<option value="30">30 </option>
<option value="31">31 </option>
<option value="32">32 </option>
<option value="33">33 </option>
<option value="34">34 </option>
<option value="35">35 </option>
<option value="36">36 </option>
<option value="37">37 </option>
<option value="38">38 </option>
<option value="39">39 </option>
<option value="40">40 </option>
<option value="41">41 </option>
<option value="42">42 </option>
<option value="43">43 </option>
<option value="44">44 </option>
<option value="45">45 </option>
<option value="46">46 </option>
<option value="47">47 </option>
<option value="48">48 </option>
<option value="49">49 </option>
<option value="50">50 </option>
<option value="51">51 </option>
<option value="52">52 </option>
<option value="53">53 </option>
<option value="54">54 </option>
<option value="55">55 </option>
<option value="56">56 </option>
<option value="57">57 </option>
<option value="58">58 </option>
<option value="59">59 </option>
<option value="60">60 </option>
<option value="61">61 </option>
<option value="62">62 </option>
<option value="63">63 </option>
<option value="64">64 </option>
<option value="65">65 </option>
<option value="66">66 </option>
<option value="67">67 </option>
<option value="68">68 </option>
<option value="69">69 </option>
<option value="70">70 </option>
<option value="71">71 </option>
<option value="72">72 </option>
<option value="73">73 </option>
<option value="74">74 </option>
<option value="75">75 </option>
<option value="76">76 </option>
<option value="77">77 </option>
<option value="78">78 </option>
<option value="79">79 </option>
<option value="80">80 </option>
<option value="81">81 </option>
<option value="82">82 </option>
<option value="83">83 </option>
<option value="84">84 </option>
<option value="85">85 </option>
<option value="86">86 </option>
<option value="87">87 </option>
<option value="88">88 </option>
<option value="89">89 </option>
<option value="90">90 </option>
<option value="91">91 </option>
<option value="92">92 </option>
<option value="93">93 </option>
<option value="94">94 </option>
<option value="95">95 </option>
<option value="96">96 </option>
<option value="97">97 </option>
<option value="98">98 </option>
<option value="99">99 </option>
<option value="100">100 </option>
</select></div>
</div>
</div>
</li>
<li id="qid65" class="frame-form-question" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="16">Diagnosed with breast/ovarian cancer</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q22-0" name="clientextra[65]" value="0"><label for="aform-frame-q22-0">No</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q22-1" name="clientextra[65]" value="1"><label for="aform-frame-q22-1">Yes</label></div>
</div>
</div>
</li>
<li id="qid66" class="frame-form-question hidden" data-related="65" data-related-answers="1" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="..">Age diagnosed with breast cancer</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q23" name="clientextra[66]">
<option value="">Please select...</option>
<option value="0" selected="selected">N.A.</option>
<option value="20">20 </option>
<option value="21">21 </option>
<option value="22">22 </option>
<option value="23">23 </option>
<option value="24">24 </option>
<option value="25">25 </option>
<option value="26">26 </option>
<option value="27">27 </option>
<option value="28">28 </option>
<option value="29">29 </option>
<option value="30">30 </option>
<option value="31">31 </option>
<option value="32">32 </option>
<option value="33">33 </option>
<option value="34">34 </option>
<option value="35">35 </option>
<option value="36">36 </option>
<option value="37">37 </option>
<option value="38">38 </option>
<option value="39">39 </option>
<option value="40">40 </option>
<option value="41">41 </option>
<option value="42">42 </option>
<option value="43">43 </option>
<option value="44">44 </option>
<option value="45">45 </option>
<option value="46">46 </option>
<option value="47">47 </option>
<option value="48">48 </option>
<option value="49">49 </option>
<option value="50">50 </option>
<option value="51">51 </option>
<option value="52">52 </option>
<option value="53">53 </option>
<option value="54">54 </option>
<option value="55">55 </option>
<option value="56">56 </option>
<option value="57">57 </option>
<option value="58">58 </option>
<option value="59">59 </option>
<option value="60">60 </option>
<option value="61">61 </option>
<option value="62">62 </option>
<option value="63">63 </option>
<option value="64">64 </option>
<option value="65">65 </option>
<option value="66">66 </option>
<option value="67">67 </option>
<option value="68">68 </option>
<option value="69">69 </option>
<option value="70">70 </option>
<option value="71">71 </option>
<option value="72">72 </option>
<option value="73">73 </option>
<option value="74">74 </option>
<option value="75">75 </option>
<option value="76">76 </option>
<option value="77">77 </option>
<option value="78">78 </option>
<option value="79">79 </option>
<option value="80">80 </option>
<option value="81">81 </option>
<option value="82">82 </option>
<option value="83">83 </option>
<option value="84">84 </option>
<option value="85">85 </option>
<option value="86">86 </option>
<option value="87">87 </option>
<option value="88">88 </option>
<option value="89">89 </option>
<option value="90">90 </option>
<option value="91">91 </option>
<option value="92">92 </option>
<option value="93">93 </option>
<option value="94">94 </option>
<option value="95">95 </option>
<option value="96">96 </option>
<option value="97">97 </option>
<option value="98">98 </option>
<option value="99">99 </option>
<option value="100">100 </option>
</select></div>
</div>
</div>
</li>
<li id="qid67" class="frame-form-question hidden" data-related="65" data-related-answers="1" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="..">Age diagnosed with a new cancer in the other breast</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q24" name="clientextra[67]">
<option value="">Please select...</option>
<option value="0" selected="selected">N.A.</option>
<option value="20">20 </option>
<option value="21">21 </option>
<option value="22">22 </option>
<option value="23">23 </option>
<option value="24">24 </option>
<option value="25">25 </option>
<option value="26">26 </option>
<option value="27">27 </option>
<option value="28">28 </option>
<option value="29">29 </option>
<option value="30">30 </option>
<option value="31">31 </option>
<option value="32">32 </option>
<option value="33">33 </option>
<option value="34">34 </option>
<option value="35">35 </option>
<option value="36">36 </option>
<option value="37">37 </option>
<option value="38">38 </option>
<option value="39">39 </option>
<option value="40">40 </option>
<option value="41">41 </option>
<option value="42">42 </option>
<option value="43">43 </option>
<option value="44">44 </option>
<option value="45">45 </option>
<option value="46">46 </option>
<option value="47">47 </option>
<option value="48">48 </option>
<option value="49">49 </option>
<option value="50">50 </option>
<option value="51">51 </option>
<option value="52">52 </option>
<option value="53">53 </option>
<option value="54">54 </option>
<option value="55">55 </option>
<option value="56">56 </option>
<option value="57">57 </option>
<option value="58">58 </option>
<option value="59">59 </option>
<option value="60">60 </option>
<option value="61">61 </option>
<option value="62">62 </option>
<option value="63">63 </option>
<option value="64">64 </option>
<option value="65">65 </option>
<option value="66">66 </option>
<option value="67">67 </option>
<option value="68">68 </option>
<option value="69">69 </option>
<option value="70">70 </option>
<option value="71">71 </option>
<option value="72">72 </option>
<option value="73">73 </option>
<option value="74">74 </option>
<option value="75">75 </option>
<option value="76">76 </option>
<option value="77">77 </option>
<option value="78">78 </option>
<option value="79">79 </option>
<option value="80">80 </option>
<option value="81">81 </option>
<option value="82">82 </option>
<option value="83">83 </option>
<option value="84">84 </option>
<option value="85">85 </option>
<option value="86">86 </option>
<option value="87">87 </option>
<option value="88">88 </option>
<option value="89">89 </option>
<option value="90">90 </option>
<option value="91">91 </option>
<option value="92">92 </option>
<option value="93">93 </option>
<option value="94">94 </option>
<option value="95">95 </option>
<option value="96">96 </option>
<option value="97">97 </option>
<option value="98">98 </option>
<option value="99">99 </option>
<option value="100">100 </option>
</select></div>
</div>
</div>
</li>
<li id="qid68" class="frame-form-question hidden" data-related="65" data-related-answers="1" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="..">Age diagnosed with ovarian cancer</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q25" name="clientextra[68]">
<option value="">Please select...</option>
<option value="0" selected="selected">N.A.</option>
<option value="20">20 </option>
<option value="21">21 </option>
<option value="22">22 </option>
<option value="23">23 </option>
<option value="24">24 </option>
<option value="25">25 </option>
<option value="26">26 </option>
<option value="27">27 </option>
<option value="28">28 </option>
<option value="29">29 </option>
<option value="30">30 </option>
<option value="31">31 </option>
<option value="32">32 </option>
<option value="33">33 </option>
<option value="34">34 </option>
<option value="35">35 </option>
<option value="36">36 </option>
<option value="37">37 </option>
<option value="38">38 </option>
<option value="39">39 </option>
<option value="40">40 </option>
<option value="41">41 </option>
<option value="42">42 </option>
<option value="43">43 </option>
<option value="44">44 </option>
<option value="45">45 </option>
<option value="46">46 </option>
<option value="47">47 </option>
<option value="48">48 </option>
<option value="49">49 </option>
<option value="50">50 </option>
<option value="51">51 </option>
<option value="52">52 </option>
<option value="53">53 </option>
<option value="54">54 </option>
<option value="55">55 </option>
<option value="56">56 </option>
<option value="57">57 </option>
<option value="58">58 </option>
<option value="59">59 </option>
<option value="60">60 </option>
<option value="61">61 </option>
<option value="62">62 </option>
<option value="63">63 </option>
<option value="64">64 </option>
<option value="65">65 </option>
<option value="66">66 </option>
<option value="67">67 </option>
<option value="68">68 </option>
<option value="69">69 </option>
<option value="70">70 </option>
<option value="71">71 </option>
<option value="72">72 </option>
<option value="73">73 </option>
<option value="74">74 </option>
<option value="75">75 </option>
<option value="76">76 </option>
<option value="77">77 </option>
<option value="78">78 </option>
<option value="79">79 </option>
<option value="80">80 </option>
<option value="81">81 </option>
<option value="82">82 </option>
<option value="83">83 </option>
<option value="84">84 </option>
<option value="85">85 </option>
<option value="86">86 </option>
<option value="87">87 </option>
<option value="88">88 </option>
<option value="89">89 </option>
<option value="90">90 </option>
<option value="91">91 </option>
<option value="92">92 </option>
<option value="93">93 </option>
<option value="94">94 </option>
<option value="95">95 </option>
<option value="96">96 </option>
<option value="97">97 </option>
<option value="98">98 </option>
<option value="99">99 </option>
<option value="100">100 </option>
</select></div>
</div>
</div>
</li>
<li id="qid69" class="frame-form-question hidden" data-related="65" data-related-answers="1" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="..">Genetic test results</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q26" name="clientextra[69]">
<option value="">Please select...</option>
<option value="0">Not tested</option>
<option value="1">I do not know</option>
<option value="2">Negative</option>
<option value="3">BRCA 1 Positive</option>
<option value="4">BRCA 2 Positive</option>
</select></div>
</div>
</div>
</li>
<li id="qid70" class="frame-form-question just-text" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="">
<p><b>Your father</b><br>Please answer the following questions regarding your Father:</p>
</div>
</li>
<li id="qid71" class="frame-form-question" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="18">Diagnosed with breast cancer</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q28-0" name="clientextra[71]" value="-1"><label for="aform-frame-q28-0">No</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q28-1" name="clientextra[71]" value="1"><label for="aform-frame-q28-1">Yes</label></div>
</div>
</div>
</li>
<li id="qid72" class="frame-form-question" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="19">Has your father had genetic testing?</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q29" name="clientextra[72]" require="">
<option value="">Please select...</option>
<option value="0">Not tested</option>
<option value="1">I do not know</option>
<option value="2">Negative</option>
<option value="3">BRCA 1 Positive</option>
<option value="4">BRCA 2 Positive</option>
</select></div>
</div>
</div>
</li>
<li id="qid73" class="frame-form-question just-text" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="">
<p><b>Your brothers</b><br>Please answer the following questions regarding your brothers</p>
</div>
</li>
<li id="qid74" class="frame-form-question" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="21">If you have any brothers, have any been diagnosed with breast cancer?</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q31-0" name="clientextra[74]" value="-1"><label for="aform-frame-q31-0">No brothers / No brothers diagnosed</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q31-1" name="clientextra[74]" value="1"><label for="aform-frame-q31-1">Yes, at least one brother diagnosed</label></div>
</div>
</div>
</li>
<li id="qid75" class="frame-form-question just-text" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="">
<p><b>Your maternal grandmother</b><br>Please answer the following questions regarding your Maternal Grandmother:</p>
</div>
</li>
<li id="qid76" class="frame-form-question" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="23">Current age or age died</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q33" name="clientextra[76]" require="">
<option value="">Please select...</option>
<option value="18">18 </option>
<option value="19">19 </option>
<option value="20">20 </option>
<option value="21">21 </option>
<option value="22">22 </option>
<option value="23">23 </option>
<option value="24">24 </option>
<option value="25">25 </option>
<option value="26">26 </option>
<option value="27">27 </option>
<option value="28">28 </option>
<option value="29">29 </option>
<option value="30">30 </option>
<option value="31">31 </option>
<option value="32">32 </option>
<option value="33">33 </option>
<option value="34">34 </option>
<option value="35">35 </option>
<option value="36">36 </option>
<option value="37">37 </option>
<option value="38">38 </option>
<option value="39">39 </option>
<option value="40">40 </option>
<option value="41">41 </option>
<option value="42">42 </option>
<option value="43">43 </option>
<option value="44">44 </option>
<option value="45">45 </option>
<option value="46">46 </option>
<option value="47">47 </option>
<option value="48">48 </option>
<option value="49">49 </option>
<option value="50">50 </option>
<option value="51">51 </option>
<option value="52">52 </option>
<option value="53">53 </option>
<option value="54">54 </option>
<option value="55">55 </option>
<option value="56">56 </option>
<option value="57">57 </option>
<option value="58">58 </option>
<option value="59">59 </option>
<option value="60">60 </option>
<option value="61">61 </option>
<option value="62">62 </option>
<option value="63">63 </option>
<option value="64">64 </option>
<option value="65">65 </option>
<option value="66">66 </option>
<option value="67">67 </option>
<option value="68">68 </option>
<option value="69">69 </option>
<option value="70">70 </option>
<option value="71">71 </option>
<option value="72">72 </option>
<option value="73">73 </option>
<option value="74">74 </option>
<option value="75">75 </option>
<option value="76">76 </option>
<option value="77">77 </option>
<option value="78">78 </option>
<option value="79">79 </option>
<option value="80">80 </option>
<option value="81">81 </option>
<option value="82">82 </option>
<option value="83">83 </option>
<option value="84">84 </option>
<option value="85">85 </option>
<option value="86">86 </option>
<option value="87">87 </option>
<option value="88">88 </option>
<option value="89">89 </option>
<option value="90">90 </option>
<option value="91">91 </option>
<option value="92">92 </option>
<option value="93">93 </option>
<option value="94">94 </option>
<option value="95">95 </option>
<option value="96">96 </option>
<option value="97">97 </option>
<option value="98">98 </option>
<option value="99">99 </option>
<option value="100">100 </option>
</select></div>
</div>
</div>
</li>
<li id="qid77" class="frame-form-question" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="24">Diagnosed with breast/ovarian cancer</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q34-0" name="clientextra[77]" value="0"><label for="aform-frame-q34-0">No</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q34-1" name="clientextra[77]" value="1"><label for="aform-frame-q34-1">Yes</label></div>
</div>
</div>
</li>
<li id="qid78" class="frame-form-question hidden" data-related="77" data-related-answers="1" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="..">Age diagnosed with breast cancer</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q35" name="clientextra[78]">
<option value="">Please select...</option>
<option value="0" selected="selected">N.A.</option>
<option value="20">20 </option>
<option value="21">21 </option>
<option value="22">22 </option>
<option value="23">23 </option>
<option value="24">24 </option>
<option value="25">25 </option>
<option value="26">26 </option>
<option value="27">27 </option>
<option value="28">28 </option>
<option value="29">29 </option>
<option value="30">30 </option>
<option value="31">31 </option>
<option value="32">32 </option>
<option value="33">33 </option>
<option value="34">34 </option>
<option value="35">35 </option>
<option value="36">36 </option>
<option value="37">37 </option>
<option value="38">38 </option>
<option value="39">39 </option>
<option value="40">40 </option>
<option value="41">41 </option>
<option value="42">42 </option>
<option value="43">43 </option>
<option value="44">44 </option>
<option value="45">45 </option>
<option value="46">46 </option>
<option value="47">47 </option>
<option value="48">48 </option>
<option value="49">49 </option>
<option value="50">50 </option>
<option value="51">51 </option>
<option value="52">52 </option>
<option value="53">53 </option>
<option value="54">54 </option>
<option value="55">55 </option>
<option value="56">56 </option>
<option value="57">57 </option>
<option value="58">58 </option>
<option value="59">59 </option>
<option value="60">60 </option>
<option value="61">61 </option>
<option value="62">62 </option>
<option value="63">63 </option>
<option value="64">64 </option>
<option value="65">65 </option>
<option value="66">66 </option>
<option value="67">67 </option>
<option value="68">68 </option>
<option value="69">69 </option>
<option value="70">70 </option>
<option value="71">71 </option>
<option value="72">72 </option>
<option value="73">73 </option>
<option value="74">74 </option>
<option value="75">75 </option>
<option value="76">76 </option>
<option value="77">77 </option>
<option value="78">78 </option>
<option value="79">79 </option>
<option value="80">80 </option>
<option value="81">81 </option>
<option value="82">82 </option>
<option value="83">83 </option>
<option value="84">84 </option>
<option value="85">85 </option>
<option value="86">86 </option>
<option value="87">87 </option>
<option value="88">88 </option>
<option value="89">89 </option>
<option value="90">90 </option>
<option value="91">91 </option>
<option value="92">92 </option>
<option value="93">93 </option>
<option value="94">94 </option>
<option value="95">95 </option>
<option value="96">96 </option>
<option value="97">97 </option>
<option value="98">98 </option>
<option value="99">99 </option>
<option value="100">100 </option>
</select></div>
</div>
</div>
</li>
<li id="qid79" class="frame-form-question hidden" data-related="77" data-related-answers="1" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="..">Age diagnosed with a new cancer in the other breast</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q36" name="clientextra[79]">
<option value="">Please select...</option>
<option value="0" selected="selected">N.A.</option>
<option value="20">20 </option>
<option value="21">21 </option>
<option value="22">22 </option>
<option value="23">23 </option>
<option value="24">24 </option>
<option value="25">25 </option>
<option value="26">26 </option>
<option value="27">27 </option>
<option value="28">28 </option>
<option value="29">29 </option>
<option value="30">30 </option>
<option value="31">31 </option>
<option value="32">32 </option>
<option value="33">33 </option>
<option value="34">34 </option>
<option value="35">35 </option>
<option value="36">36 </option>
<option value="37">37 </option>
<option value="38">38 </option>
<option value="39">39 </option>
<option value="40">40 </option>
<option value="41">41 </option>
<option value="42">42 </option>
<option value="43">43 </option>
<option value="44">44 </option>
<option value="45">45 </option>
<option value="46">46 </option>
<option value="47">47 </option>
<option value="48">48 </option>
<option value="49">49 </option>
<option value="50">50 </option>
<option value="51">51 </option>
<option value="52">52 </option>
<option value="53">53 </option>
<option value="54">54 </option>
<option value="55">55 </option>
<option value="56">56 </option>
<option value="57">57 </option>
<option value="58">58 </option>
<option value="59">59 </option>
<option value="60">60 </option>
<option value="61">61 </option>
<option value="62">62 </option>
<option value="63">63 </option>
<option value="64">64 </option>
<option value="65">65 </option>
<option value="66">66 </option>
<option value="67">67 </option>
<option value="68">68 </option>
<option value="69">69 </option>
<option value="70">70 </option>
<option value="71">71 </option>
<option value="72">72 </option>
<option value="73">73 </option>
<option value="74">74 </option>
<option value="75">75 </option>
<option value="76">76 </option>
<option value="77">77 </option>
<option value="78">78 </option>
<option value="79">79 </option>
<option value="80">80 </option>
<option value="81">81 </option>
<option value="82">82 </option>
<option value="83">83 </option>
<option value="84">84 </option>
<option value="85">85 </option>
<option value="86">86 </option>
<option value="87">87 </option>
<option value="88">88 </option>
<option value="89">89 </option>
<option value="90">90 </option>
<option value="91">91 </option>
<option value="92">92 </option>
<option value="93">93 </option>
<option value="94">94 </option>
<option value="95">95 </option>
<option value="96">96 </option>
<option value="97">97 </option>
<option value="98">98 </option>
<option value="99">99 </option>
<option value="100">100 </option>
</select></div>
</div>
</div>
</li>
<li id="qid80" class="frame-form-question hidden" data-related="77" data-related-answers="1" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="..">Age diagnosed with ovarian cancer</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q37" name="clientextra[80]">
<option value="">Please select...</option>
<option value="0" selected="selected">N.A.</option>
<option value="20">20 </option>
<option value="21">21 </option>
<option value="22">22 </option>
<option value="23">23 </option>
<option value="24">24 </option>
<option value="25">25 </option>
<option value="26">26 </option>
<option value="27">27 </option>
<option value="28">28 </option>
<option value="29">29 </option>
<option value="30">30 </option>
<option value="31">31 </option>
<option value="32">32 </option>
<option value="33">33 </option>
<option value="34">34 </option>
<option value="35">35 </option>
<option value="36">36 </option>
<option value="37">37 </option>
<option value="38">38 </option>
<option value="39">39 </option>
<option value="40">40 </option>
<option value="41">41 </option>
<option value="42">42 </option>
<option value="43">43 </option>
<option value="44">44 </option>
<option value="45">45 </option>
<option value="46">46 </option>
<option value="47">47 </option>
<option value="48">48 </option>
<option value="49">49 </option>
<option value="50">50 </option>
<option value="51">51 </option>
<option value="52">52 </option>
<option value="53">53 </option>
<option value="54">54 </option>
<option value="55">55 </option>
<option value="56">56 </option>
<option value="57">57 </option>
<option value="58">58 </option>
<option value="59">59 </option>
<option value="60">60 </option>
<option value="61">61 </option>
<option value="62">62 </option>
<option value="63">63 </option>
<option value="64">64 </option>
<option value="65">65 </option>
<option value="66">66 </option>
<option value="67">67 </option>
<option value="68">68 </option>
<option value="69">69 </option>
<option value="70">70 </option>
<option value="71">71 </option>
<option value="72">72 </option>
<option value="73">73 </option>
<option value="74">74 </option>
<option value="75">75 </option>
<option value="76">76 </option>
<option value="77">77 </option>
<option value="78">78 </option>
<option value="79">79 </option>
<option value="80">80 </option>
<option value="81">81 </option>
<option value="82">82 </option>
<option value="83">83 </option>
<option value="84">84 </option>
<option value="85">85 </option>
<option value="86">86 </option>
<option value="87">87 </option>
<option value="88">88 </option>
<option value="89">89 </option>
<option value="90">90 </option>
<option value="91">91 </option>
<option value="92">92 </option>
<option value="93">93 </option>
<option value="94">94 </option>
<option value="95">95 </option>
<option value="96">96 </option>
<option value="97">97 </option>
<option value="98">98 </option>
<option value="99">99 </option>
<option value="100">100 </option>
</select></div>
</div>
</div>
</li>
<li id="qid81" class="frame-form-question hidden" data-related="77" data-related-answers="1" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="..">Genetic test results</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q38" name="clientextra[81]">
<option value="">Please select...</option>
<option value="0">Not tested</option>
<option value="1">I do not know</option>
<option value="2">Negative</option>
<option value="3">BRCA 1 Positive</option>
<option value="4">BRCA 2 Positive</option>
</select></div>
</div>
</div>
</li>
<li id="qid82" class="frame-form-question just-text" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="">
<p><b>Your paternal grandmother</b><br>Please answer the following questions regarding your Paternal Grandmother:</p>
</div>
</li>
<li id="qid83" class="frame-form-question" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="26">Current age or age died</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q40" name="clientextra[83]" require="">
<option value="">Please select...</option>
<option value="18">18 </option>
<option value="19">19 </option>
<option value="20">20 </option>
<option value="21">21 </option>
<option value="22">22 </option>
<option value="23">23 </option>
<option value="24">24 </option>
<option value="25">25 </option>
<option value="26">26 </option>
<option value="27">27 </option>
<option value="28">28 </option>
<option value="29">29 </option>
<option value="30">30 </option>
<option value="31">31 </option>
<option value="32">32 </option>
<option value="33">33 </option>
<option value="34">34 </option>
<option value="35">35 </option>
<option value="36">36 </option>
<option value="37">37 </option>
<option value="38">38 </option>
<option value="39">39 </option>
<option value="40">40 </option>
<option value="41">41 </option>
<option value="42">42 </option>
<option value="43">43 </option>
<option value="44">44 </option>
<option value="45">45 </option>
<option value="46">46 </option>
<option value="47">47 </option>
<option value="48">48 </option>
<option value="49">49 </option>
<option value="50">50 </option>
<option value="51">51 </option>
<option value="52">52 </option>
<option value="53">53 </option>
<option value="54">54 </option>
<option value="55">55 </option>
<option value="56">56 </option>
<option value="57">57 </option>
<option value="58">58 </option>
<option value="59">59 </option>
<option value="60">60 </option>
<option value="61">61 </option>
<option value="62">62 </option>
<option value="63">63 </option>
<option value="64">64 </option>
<option value="65">65 </option>
<option value="66">66 </option>
<option value="67">67 </option>
<option value="68">68 </option>
<option value="69">69 </option>
<option value="70">70 </option>
<option value="71">71 </option>
<option value="72">72 </option>
<option value="73">73 </option>
<option value="74">74 </option>
<option value="75">75 </option>
<option value="76">76 </option>
<option value="77">77 </option>
<option value="78">78 </option>
<option value="79">79 </option>
<option value="80">80 </option>
<option value="81">81 </option>
<option value="82">82 </option>
<option value="83">83 </option>
<option value="84">84 </option>
<option value="85">85 </option>
<option value="86">86 </option>
<option value="87">87 </option>
<option value="88">88 </option>
<option value="89">89 </option>
<option value="90">90 </option>
<option value="91">91 </option>
<option value="92">92 </option>
<option value="93">93 </option>
<option value="94">94 </option>
<option value="95">95 </option>
<option value="96">96 </option>
<option value="97">97 </option>
<option value="98">98 </option>
<option value="99">99 </option>
<option value="100">100 </option>
</select></div>
</div>
</div>
</li>
<li id="qid84" class="frame-form-question" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="27">Diagnosed with breast/ovarian cancer</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q41-0" name="clientextra[84]" value="0"><label for="aform-frame-q41-0">No</label></div>
</div>
<div class="form-fields">
<div class="form-field input-radio"><input type="radio" id="aform-frame-q41-1" name="clientextra[84]" value="1"><label for="aform-frame-q41-1">Yes</label></div>
</div>
</div>
</li>
<li id="qid85" class="frame-form-question hidden" data-related="84" data-related-answers="1" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="..">Age diagnosed with breast cancer</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q42" name="clientextra[85]">
<option value="">Please select...</option>
<option value="0" selected="selected">N.A.</option>
<option value="20">20 </option>
<option value="21">21 </option>
<option value="22">22 </option>
<option value="23">23 </option>
<option value="24">24 </option>
<option value="25">25 </option>
<option value="26">26 </option>
<option value="27">27 </option>
<option value="28">28 </option>
<option value="29">29 </option>
<option value="30">30 </option>
<option value="31">31 </option>
<option value="32">32 </option>
<option value="33">33 </option>
<option value="34">34 </option>
<option value="35">35 </option>
<option value="36">36 </option>
<option value="37">37 </option>
<option value="38">38 </option>
<option value="39">39 </option>
<option value="40">40 </option>
<option value="41">41 </option>
<option value="42">42 </option>
<option value="43">43 </option>
<option value="44">44 </option>
<option value="45">45 </option>
<option value="46">46 </option>
<option value="47">47 </option>
<option value="48">48 </option>
<option value="49">49 </option>
<option value="50">50 </option>
<option value="51">51 </option>
<option value="52">52 </option>
<option value="53">53 </option>
<option value="54">54 </option>
<option value="55">55 </option>
<option value="56">56 </option>
<option value="57">57 </option>
<option value="58">58 </option>
<option value="59">59 </option>
<option value="60">60 </option>
<option value="61">61 </option>
<option value="62">62 </option>
<option value="63">63 </option>
<option value="64">64 </option>
<option value="65">65 </option>
<option value="66">66 </option>
<option value="67">67 </option>
<option value="68">68 </option>
<option value="69">69 </option>
<option value="70">70 </option>
<option value="71">71 </option>
<option value="72">72 </option>
<option value="73">73 </option>
<option value="74">74 </option>
<option value="75">75 </option>
<option value="76">76 </option>
<option value="77">77 </option>
<option value="78">78 </option>
<option value="79">79 </option>
<option value="80">80 </option>
<option value="81">81 </option>
<option value="82">82 </option>
<option value="83">83 </option>
<option value="84">84 </option>
<option value="85">85 </option>
<option value="86">86 </option>
<option value="87">87 </option>
<option value="88">88 </option>
<option value="89">89 </option>
<option value="90">90 </option>
<option value="91">91 </option>
<option value="92">92 </option>
<option value="93">93 </option>
<option value="94">94 </option>
<option value="95">95 </option>
<option value="96">96 </option>
<option value="97">97 </option>
<option value="98">98 </option>
<option value="99">99 </option>
<option value="100">100 </option>
</select></div>
</div>
</div>
</li>
<li id="qid86" class="frame-form-question hidden" data-related="84" data-related-answers="1" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="..">Age diagnosed with a new cancer in the other breast</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q43" name="clientextra[86]">
<option value="">Please select...</option>
<option value="0" selected="selected">N.A.</option>
<option value="20">20 </option>
<option value="21">21 </option>
<option value="22">22 </option>
<option value="23">23 </option>
<option value="24">24 </option>
<option value="25">25 </option>
<option value="26">26 </option>
<option value="27">27 </option>
<option value="28">28 </option>
<option value="29">29 </option>
<option value="30">30 </option>
<option value="31">31 </option>
<option value="32">32 </option>
<option value="33">33 </option>
<option value="34">34 </option>
<option value="35">35 </option>
<option value="36">36 </option>
<option value="37">37 </option>
<option value="38">38 </option>
<option value="39">39 </option>
<option value="40">40 </option>
<option value="41">41 </option>
<option value="42">42 </option>
<option value="43">43 </option>
<option value="44">44 </option>
<option value="45">45 </option>
<option value="46">46 </option>
<option value="47">47 </option>
<option value="48">48 </option>
<option value="49">49 </option>
<option value="50">50 </option>
<option value="51">51 </option>
<option value="52">52 </option>
<option value="53">53 </option>
<option value="54">54 </option>
<option value="55">55 </option>
<option value="56">56 </option>
<option value="57">57 </option>
<option value="58">58 </option>
<option value="59">59 </option>
<option value="60">60 </option>
<option value="61">61 </option>
<option value="62">62 </option>
<option value="63">63 </option>
<option value="64">64 </option>
<option value="65">65 </option>
<option value="66">66 </option>
<option value="67">67 </option>
<option value="68">68 </option>
<option value="69">69 </option>
<option value="70">70 </option>
<option value="71">71 </option>
<option value="72">72 </option>
<option value="73">73 </option>
<option value="74">74 </option>
<option value="75">75 </option>
<option value="76">76 </option>
<option value="77">77 </option>
<option value="78">78 </option>
<option value="79">79 </option>
<option value="80">80 </option>
<option value="81">81 </option>
<option value="82">82 </option>
<option value="83">83 </option>
<option value="84">84 </option>
<option value="85">85 </option>
<option value="86">86 </option>
<option value="87">87 </option>
<option value="88">88 </option>
<option value="89">89 </option>
<option value="90">90 </option>
<option value="91">91 </option>
<option value="92">92 </option>
<option value="93">93 </option>
<option value="94">94 </option>
<option value="95">95 </option>
<option value="96">96 </option>
<option value="97">97 </option>
<option value="98">98 </option>
<option value="99">99 </option>
<option value="100">100 </option>
</select></div>
</div>
</div>
</li>
<li id="qid87" class="frame-form-question hidden" data-related="84" data-related-answers="1" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="..">Age diagnosed with ovarian cancer</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q44" name="clientextra[87]">
<option value="">Please select...</option>
<option value="0" selected="selected">N.A.</option>
<option value="20">20 </option>
<option value="21">21 </option>
<option value="22">22 </option>
<option value="23">23 </option>
<option value="24">24 </option>
<option value="25">25 </option>
<option value="26">26 </option>
<option value="27">27 </option>
<option value="28">28 </option>
<option value="29">29 </option>
<option value="30">30 </option>
<option value="31">31 </option>
<option value="32">32 </option>
<option value="33">33 </option>
<option value="34">34 </option>
<option value="35">35 </option>
<option value="36">36 </option>
<option value="37">37 </option>
<option value="38">38 </option>
<option value="39">39 </option>
<option value="40">40 </option>
<option value="41">41 </option>
<option value="42">42 </option>
<option value="43">43 </option>
<option value="44">44 </option>
<option value="45">45 </option>
<option value="46">46 </option>
<option value="47">47 </option>
<option value="48">48 </option>
<option value="49">49 </option>
<option value="50">50 </option>
<option value="51">51 </option>
<option value="52">52 </option>
<option value="53">53 </option>
<option value="54">54 </option>
<option value="55">55 </option>
<option value="56">56 </option>
<option value="57">57 </option>
<option value="58">58 </option>
<option value="59">59 </option>
<option value="60">60 </option>
<option value="61">61 </option>
<option value="62">62 </option>
<option value="63">63 </option>
<option value="64">64 </option>
<option value="65">65 </option>
<option value="66">66 </option>
<option value="67">67 </option>
<option value="68">68 </option>
<option value="69">69 </option>
<option value="70">70 </option>
<option value="71">71 </option>
<option value="72">72 </option>
<option value="73">73 </option>
<option value="74">74 </option>
<option value="75">75 </option>
<option value="76">76 </option>
<option value="77">77 </option>
<option value="78">78 </option>
<option value="79">79 </option>
<option value="80">80 </option>
<option value="81">81 </option>
<option value="82">82 </option>
<option value="83">83 </option>
<option value="84">84 </option>
<option value="85">85 </option>
<option value="86">86 </option>
<option value="87">87 </option>
<option value="88">88 </option>
<option value="89">89 </option>
<option value="90">90 </option>
<option value="91">91 </option>
<option value="92">92 </option>
<option value="93">93 </option>
<option value="94">94 </option>
<option value="95">95 </option>
<option value="96">96 </option>
<option value="97">97 </option>
<option value="98">98 </option>
<option value="99">99 </option>
<option value="100">100 </option>
</select></div>
</div>
</div>
</li>
<li id="qid88" class="frame-form-question hidden" data-related="84" data-related-answers="1" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="..">Genetic test results</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="aform-frame-q45" name="clientextra[88]">
<option value="">Please select...</option>
<option value="0">Not tested</option>
<option value="1">I do not know</option>
<option value="2">Negative</option>
<option value="3">BRCA 1 Positive</option>
<option value="4">BRCA 2 Positive</option>
</select></div>
</div>
</div>
</li>
<li id="qid89" class="frame-form-question just-text" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="">
<p><b>Sisters</b><br>Please answer the following questions regarding your Sisters:</p>
</div>
</li>
<li id="qid90" class="frame-form-question" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="29">Number of sisters (total)</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="sisters" name="clientextra[90]" require="" data-code="SO">
<option value="">Please select...</option>
<option value="-1">None</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select></div>
</div>
</div>
</li>
<li id="qid91" class="frame-form-question hidden" data-related="90" data-related-answers="1,2,3,4,5,6,7,8,9,10,11,12" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="..">Number of sisters with personal history of breast or ovarian cancer</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="sistersNoOK" name="clientextra[91]" data-code="SO">
<option value="">Please select...</option>
<option value="-1">None</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select></div>
</div>
</div>
</li>
<li id="qid92" class="frame-form-question hidden just-text" data-related="91" data-related-answers="1,2,3,4,5,6,7,8,9,10,11,12" data-remove-if="|115:-1|118:1|">
<div id="bcraSO" data-primary-select="sisters"></div>
</li>
<li id="qid93" class="frame-form-question just-text" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="">
<p><b>Half Sisters</b><br>Please answer the following questions regarding your Half Sisters:</p>
</div>
</li>
<li id="qid94" class="frame-form-question" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="31">Number of half sisters (total)</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="halfsisters" name="clientextra[94]" require="" data-code="HS">
<option value="">Please select...</option>
<option value="-1">None</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select></div>
</div>
</div>
</li>
<li id="qid95" class="frame-form-question hidden" data-related="94" data-related-answers="1,2,3,4,5,6,7,8,9,10,11,12" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="..">Number of half sisters with personal history of breast or ovarian cancer</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="halfsistersNoOK" name="clientextra[95]" data-code="HS">
<option value="">Please select...</option>
<option value="-1">None</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select></div>
</div>
</div>
</li>
<li id="qid96" class="frame-form-question hidden just-text" data-related="95" data-related-answers="1,2,3,4,5,6,7,8,9,10,11,12" data-remove-if="|115:-1|118:1|">
<div id="bcraHS" data-primary-select="halfsisters"></div>
</li>
<li id="qid97" class="frame-form-question just-text" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="">
<p><b>Maternal Aunts</b><br>Please answer the following questions regarding your Maternal Aunts:</p>
</div>
</li>
<li id="qid98" class="frame-form-question" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="33">Number of maternal aunts (total)</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="maunts" name="clientextra[98]" require="" data-code="MA">
<option value="">Please select...</option>
<option value="-1">None</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select></div>
</div>
</div>
</li>
<li id="qid99" class="frame-form-question hidden" data-related="98" data-related-answers="1,2,3,4,5,6,7,8,9,10,11,12" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="..">Number of maternal aunts with personal history of breast or ovarian cancer</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="mauntsNoOK" name="clientextra[99]" data-code="MA">
<option value="">Please select...</option>
<option value="-1">None</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select></div>
</div>
</div>
</li>
<li id="qid100" class="frame-form-question hidden just-text" data-related="99" data-related-answers="1,2,3,4,5,6,7,8,9,10,11,12" data-remove-if="|115:-1|118:1|">
<div id="bcraMA" data-primary-select="maunts"></div>
</li>
<li id="qid101" class="frame-form-question just-text" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="">
<p><b>Paternal Aunts</b><br>Please answer the following questions regarding your Paternal Aunts:</p>
</div>
</li>
<li id="qid102" class="frame-form-question" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="35">Number of paternal aunts (total)</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="paunts" name="clientextra[102]" require="" data-code="PA">
<option value="">Please select...</option>
<option value="-1">None</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select></div>
</div>
</div>
</li>
<li id="qid103" class="frame-form-question hidden" data-related="102" data-related-answers="1,2,3,4,5,6,7,8,9,10,11,12" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="..">Number of paternal aunts with personal history of breast or ovarian cancer</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="pauntsNoOK" name="clientextra[103]" data-code="PA">
<option value="">Please select...</option>
<option value="-1">None</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select></div>
</div>
</div>
</li>
<li id="qid104" class="frame-form-question hidden just-text" data-related="103" data-related-answers="1,2,3,4,5,6,7,8,9,10,11,12" data-remove-if="|115:-1|118:1|">
<div id="bcraPA" data-primary-select="paunts"></div>
</li>
<li id="qid105" class="frame-form-question just-text" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="">
<p><b>Daughters</b><br>Please answer the following questions regarding your Daughters:</p>
</div>
</li>
<li id="qid106" class="frame-form-question" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="37">Number of Daughters (total)</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="daughters" name="clientextra[106]" data-code="D">
<option value="">Please select...</option>
<option value="-1">None</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select></div>
</div>
</div>
</li>
<li id="qid107" class="frame-form-question hidden" data-related="106" data-related-answers="1,2,3,4,5,6,7,8,9,10,11,12" data-remove-if="|115:-1|118:1|">
<div class="frame-form-question-text" data-num="..">Number of Daughters with a personal history of breast or ovarian cancer</div>
<div class="frame-form-question-input input-radio">
<div class="form-fields">
<div class="form-field input-text"><select id="daughtersNoOK" name="clientextra[107]" data-code="D">
<option value="">Please select...</option>
<option value="-1">None</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select></div>
</div>
</div>
</li>
<li id="qid108" class="frame-form-question hidden just-text" data-related="107" data-related-answers="1,2,3,4,5,6,7,8,9,10,11,12" data-remove-if="|115:-1|118:1|">
<div id="bcraD" data-primary-select="daughters"></div>
</li>
<li id="qidsubmit" class="frame-form-question">
<div class="form-fields">
<div class="form-field button"><input id="submit-medical" class="solid" type="submit" value="Save questionnaire"></div>
</div>
</li>
</ol>
</div>
</form><form id="loginFormForm" action="" autocomplete="off">
<div class="form-fields">
<div class="form-field input-text">
<label for="patientlogin[email]">Email</label>
<input type="text" id="login-email" name="patientlogin[email]" placeholder="Email" required="required">
<div class="error-message-wrap">
<span class="error-message">Please enter a valid email</span>
</div>
</div>
<div class="form-field input-text">
<label for="patientlogin[password]">Password</label>
<input type="password" id="login-pass" name="patientlogin[password]" placeholder="Password" required="required">
<div class="error-message-wrap">
<span class="error-message">Please enter a password</span>
</div>
<div class="teal-text">
<a id="forgotten-password-link" href="#">Forgotten password?</a>
</div>
</div>
<div class="payment-billing-card wrap-block-to-fifty">
<div class="form-field input-text" style="margin-bottom:0;">
<label style="margin-bottom:0;">Date of Birth</label>
</div>
<div class="form-field input-text threebox">
<label for="patientlogin[dob-day]">Day</label>
<label for="patientlogin[dob-month]">Month</label>
<label for="patientlogin[dob-year]">Year</label>
<input type="text" id="login-dob-day" maxlength="2" name="patientlogin[dob-day]" placeholder="" required="required">
<input type="text" id="login-dob-month" maxlength="2" name="patientlogin[dob-month]" placeholder="" required="required">
<input type="text" id="login-dob-year" maxlength="4" name="patientlogin[dob-year]" placeholder="" required="required">
</div>
</div>
<div class="form-field button">
<div id="response-error-login" class="error-message-wrap">
<span class="error-message"></span>
</div>
<button id="login-submit" class="solid" type="submit">Login</button>
<input type="hidden" name="patientlogin[format]" value="json">
</div>
</div>
</form><form id="loginForgotForm" action="" autocomplete="off" class="hidden">
<div class="form-fields">
<div class="form-field input-text">
<label for="forgotlogin[email]">Email</label>
<input type="text" id="forgot-email" name="forgotlogin[email]" placeholder="Email" required="required">
<div class="error-message-wrap">
<span class="error-message">Please enter a valid email</span>
</div>
</div>
<div class="payment-billing-card wrap-block-to-fifty">
<div class="form-field input-text" style="margin-bottom:0;">
<label style="margin-bottom:0;">Date of Birth</label>
</div>
<div class="form-field input-text threebox">
<label for="forgotlogin[dob-day]">Day</label>
<label for="forgotlogin[dob-month]">Month</label>
<label for="forgotlogin[dob-year]">Year</label>
<input type="text" id="forgot-dob-day" maxlength="2" name="forgotlogin[dob-day]" placeholder="" required="required">
<input type="text" id="forgot-dob-month" maxlength="2" name="forgotlogin[dob-month]" placeholder="" required="required">
<input type="text" id="forgot-dob-year" maxlength="4" name="forgotlogin[dob-year]" placeholder="" required="required">
</div>
</div>
<div class="form-field button" style="display:block;text-align:right;">
<div id="response-error-forgot" class="error-message-wrap">
<span class="error-message"></span>
</div>
<input id="forgot-cancel" class="solid" type="button" value="Cancel">
<input id="forgot-submit" class="solid" type="submit" value="Request reset">
<input type="hidden" name="forgotlogin[format]" value="json">
</div>
</div>
</form><form id="resetFormForm" action="" autocomplete="off">
<div class="form-fields">
<p class="explainer hidden"><b>Since your last service with us we have added password protection to your account.</b> Please set your password now by confirming your date of birth, and entering a new password.</p>
<div class="form-field input-text">
<label for="resetlogin[email]">Email</label>
<input type="text" id="resetlogin-email" name="resetlogin[email]" value="" placeholder="Email" required="required">
<div class="error-message-wrap">
<span class="error-message">Please enter a valid email</span>
</div>
</div>
<div class="form-field input-text">
<label for="resetlogin[password]">New Password</label>
<input autocomplete="off" type="password" id="resetlogin-password" name="resetlogin[password]" placeholder="" required="required">
<div class="error-message-wrap">
<span class="error-message">Please enter a valid password</span>
</div>
</div>
<!--
<div class="form-field input-text">
<label for="resetlogin[password_confirm]">Confirm Password</label>
<input autocomplete="off" type="password" id="resetlogin-password-confirm" name="resetlogin[password_confirm]" autocomplete="new-password" placeholder="" required="required">
<div class="error-message-wrap">
<span class="error-message">Please reenter your password</span>
</div>
</div>
-->
<div class="payment-billing-card wrap-block-to-fifty">
<div class="form-field input-text" style="margin-bottom:0;">
<label style="margin-bottom:0;">Date of Birth</label>
</div>
<div class="form-field input-text threebox">
<label for="resetlogin[dob-day]">Day</label>
<label for="resetlogin[dob-month]">Month</label>
<label for="resetlogin[dob-year]">Year</label>
<input type="text" id="resetlogin-dob-day" name="resetlogin[dob-day]" placeholder="" required="required">
<input type="text" id="resetlogin-dob-month" name="resetlogin[dob-month]" placeholder="" required="required">
<input type="text" id="resetlogin-dob-year" name="resetlogin[dob-year]" placeholder="" required="required">
</div>
</div>
<div class="form-field input-text hidden">
<label for="resetlogin[code]">Code</label>
<input type="text" id="login-code" name="resetlogin[code]" value="" placeholder="Reset code" required="required" readonly="" onfocus="this.removeAttribute('readonly');" onblur="this.setAttribute('readonly','');">
<div class="error-message-wrap">
<span class="error-message">Please enter your reset code</span>
</div>
</div>
<div class="form-field button">
<div id="response-error-resetlogin" class="error-message-wrap">
<span class="error-message"></span>
</div>
<button id="resetlogin-submit" class="solid" type="submit">Submit</button>
<input type="hidden" name="resetlogin[format]" value="json">
</div>
</div>
</form>Text Content
Individual Employee Benefits
0800 085 6663
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* Private cancer tests
* Bowel Cancer Test
* Breast Cancer Test
* Cancer Genetic Testing & Genetic Counselling
* Cervical Cancer Test
* Lung Cancer Test
* Prostate Cancer Test
* Skin Cancer Test and Mole Checks
* Screening Mammogram
* Advice and Awareness
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* Lung Cancer
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* Skin Cancer
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* Blog
Clinic locator
Individual Employee Benefits
12 ways to reduce your cancer risk
Find out more
* Bowel Cancer Test
* Breast Cancer Test
* Cancer Genetic Testing & Genetic Counselling
* Cervical Cancer Test
* Lung Cancer Test
* Prostate Cancer Test
* Skin Cancer Test and Mole Checks
* Screening Mammogram
BowelCheck
BowelCheck, our reliable at-home bowel cancer test kit, is a sample collection
kit that looks for signs of digested human blood in your stools. Order online.
OneStop Breast Clinic
Check4Cancer's OneStop Breast Clinic provides rapid access to all diagnostic
tests at the first appointment. Contact your private medical insurer today.
Genetic Cancer Testing
Find out if you are at increased risk of developing cancer with fast, accurate
genetic testing. Genetic counselling is offered before and after all genetic
tests.
HPVCheck
HPVCheck is a comfortable and reliable at-home cervical cancer test kit that
looks for the Human Papillomavirus (HPV), the virus that causes cervical cancer.
LungCheck
LungCheck is an easy to use at-home lung cancer test kit that screens for
antibodies that can be linked to an increased risk of developing lung cancer.
PSACheck
PSACheck is an affordable, easy to use at-home prostate cancer test kit for men
aged 40+. Order your PSA test today and receive results within 7 days.
SkinCheck
Private skin cancer screening to investigate skin lesions or to get your moles
checked by skin cancer specialists from Check4Cancer. Book your appointment.
Screening mammogram to detect early breast cancer
Book your private mammogram screening with Check4Cancer today, to detect breast
cancer at an early stage before changes can be felt in the breast.
* Bowel Cancer
* Breast Cancer
* Cervical Cancer
* Lung Cancer
* Prostate Cancer
* Skin Cancer
* Genetics
* Blog
Bowel Cancer
What is bowel cancer? Discover the symptoms, causes, risk factors, tests and
treatments of bowel cancer with Check4Cancer’s comprehensive guide.
Breast Cancer
What is breast cancer? This comprehensive guide covers the causes, symptoms,
risk factors and treatments of breast cancer. Read on to find out.
Cervical Cancer
What is cervical cancer? Find out about the risk factors, symptoms, causes,
tests and treatments for cervical cancer, as well as how to order an HPV test.
Lung Cancer
Lung cancer is one of the most common types of cancer. Learn about the symptoms,
causes, treatment and how to get a diagnosis with our in-depth guide.
Prostate Cancer
Discover the symptoms, causes, risk factors and treatments of prostate cancer
with Check4Cancer’s comprehensive guide. Read on to find out more.
Skin Cancer
Information about skin cancer risks, signs and symptoms and when to book a skin
cancer test. Check4Cancer offers skin cancer tests and mole check services.
Genetics
Read our comprehensive guide to genetic testing cancer to learn more about how
genetic cancer testing works and how a genetic counsellor can help.
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YOUR PERSONALISED SCREENING PROGRAMME
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results. This means that we will send you a reminder email when your next
screening test is due.
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For MyBreastRisk, the detail of your result will be improved if you are able to
answer the following questions about your lifestyle and family history. The more
information you are able to provide will assist in providing you with the most
accurate result. If you cannot answer all questions, some information is better
than none, especially if you are aware of any family members diagnosed with
breast or ovarian cancer.
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MyBreastRisk 281
THANK YOU FOR CHOOSING MYBREASTRISK, OUR AT-HOME DNA SALIVA SAMPLE COLLECTION
KIT TO DETERMINE YOUR PERSONAL RISK OF DEVELOPING BREAST CANCER.
* We provide you with a personalised screening programme.
* Results from your DNA test and questionnaire results will give you a
'Lifetime Risk Score'.
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MyBreastRisk 281
THANK YOU FOR CHOOSING MYBREASTRISK, OUR AT-HOME DNA SALIVA SAMPLE COLLECTION
KIT TO DETERMINE YOUR PERSONAL RISK OF DEVELOPING BREAST CANCER.
* We provide you with a personalised screening programme.
* Results from your DNA test and questionnaire results will give you a
'Lifetime Risk Score'.
Free recorded delivery in discrete packaging within two working days.
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Name: {client_name}
Date of birth: {client_dob_day} {client_dob_month} {client_dob_year}
Sex: {client_sex}
Email: {client_email}
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Expiry date: {card_expire_month}/{card_expire_year}
Plan
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Place your order
Risk Questions
1 of 37
Answered
1. Weight
Please select...6st / 38.1kg6st 3 lbs / 39.5kg6st 7 lbs / 41.3kg6st 10 lbs
/ 42.6kg6st 13 lbs / 44.0kg7st 2 lbs / 45.4kg7st 6 lbs / 47.2kg7st 9 lbs /
48.5kg7st 12 lbs / 49.9kg8st 2 lbs / 51.7kg8st 5 lbs / 53.1kg8st 8 lbs /
54.4kg8st 12 lbs / 56.2kg9st 1 lbs / 57.6kg9st 4 lbs / 59.0kg9st 7 lbs /
60.3kg9st 11 lbs / 62.1kg10st / 63.5kgPlease select...10st 4 lbs /
65.3kg10st 8 lbs / 67.1kg10st 13 lbs / 69.4kg11st 4 lbs / 71.7kg11st 9 lbs
/ 73.9kg11st 13 lbs / 75.7kg12st 4 lbs / 78.0kg12st 9 lbs / 80.3kg13st /
82.6kg13st 4 lbs / 84.4kg13st 9 lbs / 86.6kg14st / 88.9kg14st 4 lbs /
90.7kg14st 9 lbs / 92.9kg15st / 95.2kg15st 4 lbs / 97.0kg15st 9 lbs /
99.3kg16st / 101.6kg17st / 107.9kg18st / 114.3kg19st / 120.6kg20st /
127kg21st / 133.3kg22st / 139.7kg23st / 146kg24st / 152.4kg25st /
158.7kg26st / 165.1kg27st / 171.4kg28st / 177.8kg29st / 184.1kg30st /
190.5kg30st 10 lbs / 195kg31st 7 lbs / 200kg32st 4 lbs / 205kg33st 1 lbs /
210kg33st 12 lbs / 215kg34st 10 lbs / 220kg35st 7 lbs / 225kg36st 4 lbs /
230kg37st 1 lbs / 235kg37st 12 lbs / 240kg38st 9 lbs / 245kg39st 6 lbs /
250kg
2. Height
Please select...3' / 91.5cm3' 1 / 94cm3' 2 / 96.5cm3' 3 / 99cm3' 4 /
101.5cm3' 5 / 104cm3' 6 / 106.5cm3' 7 / 109cm3' 8 / 111.5cm3' 9 / 114cm3'
10 / 116.5cm3'11" / 119cm4' / 121.5cm4' 1 / 124cm4' 2 / 127cm4' 3 /
129.5cm4' 4 / 132cm4' 5 / 134.5cm4' 6 / 137cm4' 7 / 139.5cm4' 8 / 142cm4' 9
/ 144.5cm4' 10 / 147cm4' 11 / 150cm5' / 152.5cmPlease select...5' 1 /
155cm5' 2 / 157.5cm5' 3 / 160cm5' 4 / 162.5cm5' 5 / 165cm5' 6 / 167.5cm5' 7
/ 170cm5' 8 / 172.5cm5' 9 / 175cm5' 10 / 177.5cm5' 11 / 180cm6' / 183cm6' 1
/ 185.5cm6' 2 / 188cm6' 3 / 190.5cm6' 4 / 193cm6' 5 / 195.5cm6' 6 / 198cm6'
7 / 200.5cm6' 8 / 203cm6' 9 / 205.5cm6' 10 / 208cm6' 11 / 210.5cm7' /
213cm7' 1 / 216cm7' 2 / 218.5cm7' 3 / 221cm7' 4 / 223.5cm7' 5 / 226cm7' 6 /
228.5cm7' 7 / 231cm7' 8 / 233.5cm7' 9 / 236cm7' 10 / 238.5cm7' 11 / 241cm8'
/ 243.5cm
3. Have you been previously diagnosed with breast cancer?
No
Yes
4. Is there any history of breast or ovarian cancer with any blood relative in
your immediate or extended family?
No
Yes
5. Previous breast cancer?
No
Yes
6. How old were you when you had your first period?
Please select...Never
menstruated8yrs9yrs10yrs11yrs12yrs13yrs14yrs15yrs16yrs17yrs18yrs19yrs20yrs
7. Are you of Ashkenazi Jewish Ancestry?
No
Yes
8. Do you have any children?
No
Yes
9. What age did you give birth to your first child?
Please select...No
children91011121314151617181920212223242526272829303132333435363738394041424344454647484950
10. Have you been through the menopause?
Currently perimenopausal
No
Yes
11. If yes, how old were you at menopause?
Please select...Not
applicable3031323334353637383940414243444546474849505152535455565758596061626364656667686970
12. Do you or have you ever used HRT?
No
Yes
13. Started using (mm/yyyy)
14. Date last used (mm/yyyy)
15. What type?
Unknown
Oestrogen only
Combined
16. Have you had a breast biopsy in the past?
No
Yes
17. Were any of the following identified?
None
Hyperplasia
Atypical hyperplasia
LCIS (pre-cancerous cells)
Unknown
18. Have you ever had ovarian cancer?
No
Yes
19. If yes, at what age?
Please select...Not
applicable202122232425262728293031323334353637383940414243444546474849505152535455565758596061626364656667686970
20. Have you been tested for BRCA1 and/or BRCA2 mutations
Please select...Not testedI do not knowNegativeBRCA 1 PositiveBRCA 2
Positive
21. Your mother
Please answer the following questions regarding your Mother:
22. Current age or age died
Please select...18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37
38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62
63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87
88 89 90 91 92 93 94 95 96 97 98 99 100
23. Diagnosed with breast/ovarian cancer
No
Yes
24. Age diagnosed with breast cancer
Please select...N.A.20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37
38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62
63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87
88 89 90 91 92 93 94 95 96 97 98 99 100
25. Age diagnosed with a new cancer in the other breast
Please select...N.A.20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37
38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62
63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87
88 89 90 91 92 93 94 95 96 97 98 99 100
26. Age diagnosed with ovarian cancer
Please select...N.A.20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37
38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62
63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87
88 89 90 91 92 93 94 95 96 97 98 99 100
27. Genetic test results
Please select...Not testedI do not knowNegativeBRCA 1 PositiveBRCA 2
Positive
28. Your father
Please answer the following questions regarding your Father:
29. Diagnosed with breast cancer
No
Yes
30. Has your father had genetic testing?
Please select...Not testedI do not knowNegativeBRCA 1 PositiveBRCA 2
Positive
31. Your brothers
Please answer the following questions regarding your brothers
32. If you have any brothers, have any been diagnosed with breast cancer?
No brothers / No brothers diagnosed
Yes, at least one brother diagnosed
33. Your maternal grandmother
Please answer the following questions regarding your Maternal Grandmother:
34. Current age or age died
Please select...18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37
38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62
63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87
88 89 90 91 92 93 94 95 96 97 98 99 100
35. Diagnosed with breast/ovarian cancer
No
Yes
36. Age diagnosed with breast cancer
Please select...N.A.20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37
38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62
63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87
88 89 90 91 92 93 94 95 96 97 98 99 100
37. Age diagnosed with a new cancer in the other breast
Please select...N.A.20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37
38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62
63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87
88 89 90 91 92 93 94 95 96 97 98 99 100
38. Age diagnosed with ovarian cancer
Please select...N.A.20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37
38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62
63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87
88 89 90 91 92 93 94 95 96 97 98 99 100
39. Genetic test results
Please select...Not testedI do not knowNegativeBRCA 1 PositiveBRCA 2
Positive
40. Your paternal grandmother
Please answer the following questions regarding your Paternal Grandmother:
41. Current age or age died
Please select...18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37
38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62
63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87
88 89 90 91 92 93 94 95 96 97 98 99 100
42. Diagnosed with breast/ovarian cancer
No
Yes
43. Age diagnosed with breast cancer
Please select...N.A.20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37
38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62
63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87
88 89 90 91 92 93 94 95 96 97 98 99 100
44. Age diagnosed with a new cancer in the other breast
Please select...N.A.20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37
38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62
63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87
88 89 90 91 92 93 94 95 96 97 98 99 100
45. Age diagnosed with ovarian cancer
Please select...N.A.20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37
38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62
63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87
88 89 90 91 92 93 94 95 96 97 98 99 100
46. Genetic test results
Please select...Not testedI do not knowNegativeBRCA 1 PositiveBRCA 2
Positive
47. Sisters
Please answer the following questions regarding your Sisters:
48. Number of sisters (total)
Please select...None123456789101112
49. Number of sisters with personal history of breast or ovarian cancer
Please select...None123456789101112
50.
51. Half Sisters
Please answer the following questions regarding your Half Sisters:
52. Number of half sisters (total)
Please select...None123456789101112
53. Number of half sisters with personal history of breast or ovarian cancer
Please select...None123456789101112
54.
55. Maternal Aunts
Please answer the following questions regarding your Maternal Aunts:
56. Number of maternal aunts (total)
Please select...None123456789101112
57. Number of maternal aunts with personal history of breast or ovarian cancer
Please select...None123456789101112
58.
59. Paternal Aunts
Please answer the following questions regarding your Paternal Aunts:
60. Number of paternal aunts (total)
Please select...None123456789101112
61. Number of paternal aunts with personal history of breast or ovarian cancer
Please select...None123456789101112
62.
63. Daughters
Please answer the following questions regarding your Daughters:
64. Number of Daughters (total)
Please select...None123456789101112
65. Number of Daughters with a personal history of breast or ovarian cancer
Please select...None123456789101112
66.
67.
Continue without answering questions
AT CHECK4CANCER WE ARE KEEN THAT YOU HAVE AS MANY FACTS AS POSSIBLE BEFORE
TAKING A DECISION TO HAVE EARLY DETECTION OF CANCER SERVICES. WE HOPE THAT YOU
WILL FIND THE INFORMATION BELOW USEFUL.
Pros
* Cancer screening may give you an indication of cancer before any symptoms
develop.
* Cancer screening may find cancer at an early stage when treatment is more
likely to be curative.
* If cancer is diagnosed at an earlier stage, treatment is more likely to be
successful.
Cons
* Cancer screening can miss a number of cancers and provide false reassurance:
no cancer screening test is 100% accurate.
* Cancer screening can lead to unnecessary worry and investigations when there
is no cancer present.
* A positive screening result may cause anxiety by diagnosing a slow-growing
tumour that may never cause any harm or symptoms.
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