Mammography

Name *

Date of Birth *

Referring Physician:

Have you had any prior mammograms?YesNo

If yes, when ? *

where? *

Have you had a prior BREAST U/S?YesNo

If yes, when ? *

where? *

Do you have any current breast symptoms(lump, pain, nipple discharge)? if yes, please describe symptom, location & duration:

Do you have a personal history of breast cancer?YesNo

If yes, which breast and when; *

What treatment(s) did you receive:MastectomyLumpectomyHormone TherapyRadiationChemotherapy

Do you have a personal history of:

Breast Cyst AspirationYesNo

If yes, which breast *RightLeft

Benign or negative breast biopsyYesNo

If yes, which breast *RightLeft

Breast ImplantsYesNo

Breast ReductionYesNo

Do you have a family history of breast cancer?YesNo

If yes, which relative & at what age was she diagnosed?

Relation *

Age *

Relation *

Age *

When did your doctor last examine your breast

Patients Signature

Date

*If patient has current breast symptoms & is having a screening study, please give additional information regarding these symptoms

Tech Initials

Please do not fill in this field.

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