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Table 1 Questionnaire for assessment of diagnosis delay in women with breast cancer in Libya

From: Diagnosis delay in Libyan female breast cancer

File number
Age (years)
Address
Occupation House wife
  Employee
Marital status Married
  Single
Education Literate
  Illiteracy
Obstetric history Age of menarche
  Age at first pregnancy
  Oral contraceptive pills
  Number of births
  Breast feeding
Menopausal status Pre-menopausal
  Pos-menopausal
Family history Positive
  Negative
History of benign breast disease Yes
  No
Breast self examination Yes
  No
First symptoms Lump
  Nipple discharge
  Skin changes
  Systemic
Mode of First symptoms detection (first symptoms) Accidental
  Breast self examination
  Clinical examination
Action taken by the patient at appearance of the first symptoms Consult the doctor immediately
  Delay Duration of delay
   Reasons of delay
Action taken by the doctor at the first visit Refer the patient
  Medical follow-up
  Duration of follow-up
Duration between first symptoms and first visit to the doctor  
Duration between the first visit to the doctor and histopathological or cytological diagnosis  
Duration between the first symptoms and histopathological or cytological diagnosis.  
Clinical staging at time of the diagnosis (from the patients files)