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Mammogram History

The document is a Breast History and Mammogram Screening Sheet used by the Radiology Department to collect patient information prior to a breast exam. It includes sections for personal history, reasons for the exam, family history of breast cancer, and previous procedures related to breast health. Patients are required to verify the accuracy of their provided information before the exam.

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17 views1 page

Mammogram History

The document is a Breast History and Mammogram Screening Sheet used by the Radiology Department to collect patient information prior to a breast exam. It includes sections for personal history, reasons for the exam, family history of breast cancer, and previous procedures related to breast health. Patients are required to verify the accuracy of their provided information before the exam.

Uploaded by

hnawazcdc
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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RADIOLOGY DEPARTMENT

BREAST HISTORY & MAMMOGRAM SCREENING SHEET

PATIENT NAME: _________________________________________ TODAY'S DATE: _____________________


AGE: ____________________________________________________________________________________
PHONE # (H): ____________________ (W): ________________ DATE OF LAST MAMMOGRAM: _________
WHERE: _______________________________ REFERRING PHYSICIAN: ______________________________
What is the reason for having this breast exam?
This is a routine exam. I AM NOT HAVING ANY BREAST PROBLEMS.
This is a short interval follow-up requested from my last exam (1-11 months ago).
I have a personal history of cancer. Date: ______________ Location: __________________________
I am having the following new problem (s): (please check R for right or L for left)
New lump that can be felt R L Breast pain R L
Other NEW thickening R L Nipple problem R L
Bloody nipple discharge R L Non-bloody spontaneous nipple discharge R L
Other _________________ R L Large Nodes under my arm R L

DATE OF LAST PHYSICAL BREAST EXAM PERFORMED BY YOUR PHYSICIAN: __________________________


Are you taking any of the following? YES NO
Estrogen Replacement Therapy? Age first used ___________ Age last used ___________
Tamoxifen/Arimidex Age first used ___________ Age last used ___________
Progesterone? Age first used ___________ Age last used ___________

IMPORTANT: Check the following THAT ARE TRUE FOR YOU:


No one in my family has had breast cancer.
My aunt grandmother cousin father uncle had breast cancer Maternal or paternal
My mother sister had breast cancer after their periods had stopped. Age at diagnosis ___________________
My mother sister had breast cancer while they were still having their periods. Age at diagnosis ____________
I have had breast cancer. R L

Have you ever had any of the following procedures: YES NO


R L Cyst Aspiration Date: ________________
R L Needle biopsy Date: ________________
R L Excisional biopsy Date: ________________
R L Lumpectomy for Cancer Date: ________________
R L Mastectomy Date: ________________
R L Radiation Therapy Date: ________________

I verify that the answers I have provided to questions on this form are correct and understand that withholding
information or inaccurate information may adversely affect the interpretation of this exam.

Patients signature: ________________ Date: ___________________

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