Patient's Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Have you ever been diagnosed with breast cancer?

Yes

No

If Yes, when?

MM

DD

YYYY

Where was your diagnosis?

R Breast

L Breast

Date of last breast exam by a doctor:

MM

DD

YYYY

What was your breast exam result?

Normal

Lump

Thickening

R

L

Date of your last mammogram

MM

DD

YYYY

Was your mammogram:

Normal

Abnormal

Suspicious

Watchful

R Breast

L Breast

Date of your last breast ultrasound:

MM

DD

YYYY

Were both breasts imaged?

Yes

No

Was the ultrasound:

Normal

Abnormal

Suspicious

Watchful

R Breast

L Breast

Was a follow up biopsy recommended after your LAST mammogram, ultrasound, or MRI?

Yes

No

Date of any breast biopsies:

MM

DD

YYYY

Which breast was biopsied:

R Breast

L Breast

What was found on the biopsy?

Cancer

Other

R Breast

L Breast

Have you had a mastectomy?

Complete

Partial

R Breast

L Breast

Date of mastectomy

MM

DD

YYYY

Was the nipple removed?

Yes

No

Was the surface skin of the original breast entirely removed?

Yes

No

Any breast radiation treatment? Date of last treatment

MM

DD

YYYY

Which breast was the radiation treatment:

R

L

Are you currently pregnant?

Yes

No

Are you currently nursing?

Yes

No

Are you CURRENTLY experiencing any of the following with your breasts:

None

Lump

Thickening (provide date found and by whom)

Dull Pain

Sharp Pain

Burning Pain

Stinging Pain

Tenderness

Pain changes with my cycle

Skin Changes: Color

Skin Changes: Texture

Skin Changes: Over the lump

RIGHT Breast Nipple Discharge

Bloody

Milky

Clear

Through 1 duct

Through multiple ducts

Other (Specify below)

LEFT Breast Nipple Discharge

Bloody

Milky

Clear

Through 1 duct

Through multiple ducts

Other (Specify below)

RIGHT Breast Nipple Retraction

For many years

Recently

LEFT Breast Nipple Retraction

For Many Years

Recently

RIGHT Nipple Changes

Color

Texture

Other (Specify Below)

LEFT Nipple Changes

Color

Texture

Other (Specify Below)