PATIENT BREAST INFORMATION

NAME:_________________________________________AGE:_______DATE:____/______/_______

 PERSONAL BREAST HISTORY   
     PREVIOUS BREAST BIOPSY                    YES       NO        IF YES-WHEN________________________

    PREVIOUS BREAST SURGERY                 YES       NO       IF YES-WHEN_________________________

                                                                             WHAT TYPE______________________________________

FAMILY HISTORY OF BREAST CANCER          YES        NO

                 IF YES:   MOTHER___AGE______ SISTER(S)____AGE______ AUNT(S)____AGE______    
                     
                                 GRANDMOTHER____AGE_____ DAUGHTER____AGE_____ OTHER__________

 MENSTRUAL HISTORY:   
      1st MENSTRUAL CYCLE-AGE_____      MENOPAUSE-AGE_______                                              
           LAST MENSTRUAL CYCLE______________

 HORMONE USE: ORAL CONTRACEPTIVE_______ HORMONE REPLACEMENT________
CHILDBIRTH HISTORY:  # OF PREGNANCIES______________# OF CHILDREN___________
                                              AGE AT 1ST LIVE BIRTH______ BREAST FEEDING HISTORY   YES    NO

DO YOU DO REGULAR SELF BREAST EXAMS     NO            YES           HOW OFTEN?
DO YOU HAVE CAFFIENE REGULARLY?     NO        YES         SOURCE AND HOW OFTEN?
ARE YOU ON BLOOD THINNERS?        NO        YES                           
DO YOU HAVE A PACEMAKER/DEFIBRILLATOR?      NO      YES

MAMMOGRAM                     YES                 NO            DATE OF EXAM_______________
BREAST US                            YES                 NO            DATE OF EXAM_______________

BREAST MRI                          YES                 NO            DATE OF EXAM_______________


REASON FOR TODAYS VISIT:
      BREAST LUMP                                            RT                    LT         FIRST NOTICED______________

      BREAST PAIN                                              RT                    LT         FIRST NOTICED______________

     NIPPLE DISCHARGE                                   RT                    LT         FIRST NOTICED______________

     CHANGE IN BREAST APPEARANCE:      RT                    LT         FIRST NOTICED______________

     ABNORMAL MAMMOGRAM                    RT                    LT

    SECOND OPINION

 PREVIOUS BREAST CANCER TREATMENT                    YES     NO

                          LUMPECTOMY                         YES     NO               RT         LT

                          RADIATION THERAPY            YES     NO              RT        LT

                          MASTECTOMY                          YES     NO              RT         LT    WHEN?____________
                                             WITH OR WITHOUT RECONSTRUCTION

                          CHEMOTHERAPY                      YES      NO