Download RADIOLOGIST USE: BIRADS Density US MRI If no MRI, Then U/S

Patient Name: __________________________________ Date of Birth: ______________________
Appointment Date: _____________________________ SSN#:______________________________
Referring Physician:
PLEASE NOTIFY US IF YOU ARE PREGNANT OR COULD POSSIBLY BE PREGNANT
1. When was your last Mammogram? _____________________________
2.
Where was your last Mammogram performed?
Columbus Clinic
Columbus Diagnostic Center
Columbus Regional Breast Care Center
Martin Army
Here - Pink Monarch
St. Francis
Other ______________________________________________________________________
3.
Have you had Breast Cancer?
No
Yes – Date of Diagnosis ____________________________________________________
How treated?
Surgery
Chemo
Radiation
TECH USE ONLY:
Note
Tamoxifen
4. Have you had a significant weight loss since your last mammogram? _________
Risk Calculation
5. Do you have children?
PACS
Yes, your age at first birth __________
No
BRCA
6. Are you taking birth control or fertility medications?
No
Yes, for how long? _____________________
Initials _____________
7. How old were you when you started having periods?__________
8. Please answer ONE of the following:
RADIOLOGIST USE:
Date of Last Menstrual Period _____________________ OR
BIRADS
Year of Menopause_________________________________ OR
Density
US
Year of Hysterectomy or Ablation _________________
MRI
9. Are you taking Hormones (Estrogen / Progesterone / HRT)?
No
Yes, for how long__________________________
10. Do you have Rheumatoid Arthritis?
No
If no MRI,
Then U/S
Yes
IF YOU HAVE EVER HAD BREAST SURGERY OR HAVE A FAMILY HISTORY OF
BREAST OR OVARIAN CANCER PLEASE COMPLETE PAGE 2.
11. Have you ever had Breast Surgery?
No
Surgical Biopsy
R
L
Details_______________________
Needle Biopsy
R
L
Details_______________________
Cyst Aspiration
R
L
Details_______________________
Breast Implants: Date______________
No Revision
Silicone
Saline
Yes Revision
Breast Reduction: Date______________ Complications____________
Breast Lift: Date______________ Complications____________
12. Please circle Y to those that apply to YOU and/or YOUR FAMILY (on both
MOTHER and FATHER’s side). Please list your relationship to the individual
diagnosed and the age at cancer diagnosis (consider parents, siblings, grandparents
aunts/uncles, nieces/nephews and children)
-
Anyone with breast cancer before age 50
Y
N
Age ______
Relationship: ____________________________________
-
Anyone with breast cancer after age 50
Y
N
Age ______
Relationship: ____________________________________
-
Anyone with cancer in both breasts
Y
N
Age ______
Relationship: ____________________________________
-
Any males with breast cancer at any age?
Y
N
Age ______
Relationship: ____________________________________
-
Ashkenazi Jewish with a personal or family
history of breast or ovarian cancer?
Y
N
Age ______
Relationship: ____________________________________
-
Anyone with family had Pancreatic Cancer?
Y
N
Age ______
Relationship: ____________________________________
-
Anyone with ovarian cancer?
Y
N
Age ______
Relationship: ____________________________________
13. Have you ever had the BRCA (Breast Cancer Gene Test?)
No
Yes – if Yes Results:
Negative
Positive
Height:____________________
Weight:__________________
Race: ____________________