BREAST HEALTH HISTORY FORM

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1 BREAST HEALTH HISTORY FORM Name Date of Visit: Date of Birth: Age: REFERRING PHYSICIANS: please include name, address and phone number of all physicians whom you would like to receive report of today s visit Primary Care: OBGYN:_ Other: How did you find out about the breast center? Physician referral newspaper Friend / family internet Mailing phone book Other SECTION #1 PAST BREAST HEALTH Please list any breast surgeries or procedures that you have had and mark any scars on the diagram Open biopsy Needle biopsy Lumpectomy Right Left Date Result Doctor Notes Implants saline/silicone above muscle / below muscle Mastectomy Axillary surgery Breast reduction Breast lift Other N/A N/A 1

2 Current BRA size: Married Single Divorced Widowed Significant other Current occupation: Hours worked per week: Support at home: Y N Please answer yes or no to the following and indicate R or L breast or Both. R L Both 1. Do you have a history of breast cancer? IF YES, THEN: Date of diagnosis: R L Both radiation treatments anti-hormone therapy--type: chemotherapy--type: R L Both 2. Have you had fluid-filled breast cysts? IF YES, THEN: R L Both Have they been drained with a needle Removed with surgical excision R L Both 3. Have you had FIBROADENOMAs of the breast? IF YES, THEN: R L Both Were they biopsied with a needle Removed with surgical excision R L Both 4. Other benign or malignant breast conditions 2

3 SECTION #2 RISK FACTORS 1. Have you ever had radiation to your head / neck / chest? 2. Do you have children? IF YES, THEN: Did you breast feed any child greater than six weeks? Were you 30 yrs of age or younger at first pregnancy? 3. Were you 12 yrs of age or younger when you began menstruating? Age when you first began menstruating: 4. Do you still have menstrual periods? IF YES, THEN: Are they regular? Date of last menstrual cycle: IF NO, THEN: Did your menstrual periods persist after age 54? NATURAL or SURGICAL menopause: age 5. Do you smoke cigarettes? date quit packs per day years 6. Do you drink alcohol? drinks per week 7. Do you have a family history of breast cancer? Please list all family members (maternal and paternal) and their ages at diagnosis: 8. Do you have a family history of ovarian cancer? Please list all family members (maternal and paternal) and their ages at diagnosis: 9. Do you have a family history of other cancers? Please list all family members, their ages at diagnosis and the type of cancer: 10. Have you ever taken or are you currently taking hormone replacement therapy? What type? How long? 11. Do you have a personal history of cancer (other than breast)? Please describe TYPE, TREATMENTS, DATES: 3

4 SECTION #4 PAST MEDICAL HISTORY MEDICATION (Rx, OTC, Herbal) DOSE FREQUENCY ALLERGIES REACTION SURGICAL PROCEDURES DATE PERFORMED 4

5 PLEASE CIRCLE ANY OF THE FOLLOWING SYMTOMS THAT YOU HAVE OR HAD IN THE PAST: GENERAL Fever or chills Weight loss Loss of appetite Weight gain ENT Cough Cold Sinus infection Snoring Hearing loss CARDIOVASCULAR Shortness of breath Difficulty breathing Heart attack Valve problems Blood clots Rheumatic fever Abnormal heart rhythm High blood pressure Decreased exercise tolerance Other heart problems GASTROINTESTINAL Abdominal pain Liver problems Gallstones Jaundice Hepatitis Ulcers Colititis Colon cancer Hiatal Hernia Reflux Pancreatitis Nausea / vomiting Intestinal bleeding Constipation Diarrhea GYNECOLOGIC Abnormal vaginal bleeding Incontinence Hot flashes Sexually transmitted diseases RENAL Kidney failure I dialysis Burning or pain with urination Recurrent urinary infections Kidney stones Blood in urine Frequent urination Difficulty urinating MUSCULOSKELETAL Joint pains Arthritis Muscle aches Bone pain PULMONARY Emphysema Pneumonia Asthma Wheezing Shortness of Breath Lung operations Chronic Bronchitis Tuberculosis Coughing blood Other lung problems SKIN Ezcema Rashes Other skin problems NEUROLOGIC Numbness Tingling Stroke Weakness Seizures Dizziness Fainting spells Visual loss / changes Other ENDOCRINE Thyroid problems Diabetes Steroid usage Osteoporosis / osteopenia Other BLOOD / LYMPHATIC Hemophilia Blood clots Bleeding problems Easy bruising / bleeing Anemia Enlarged lymph nodes Leg swelling Arm sweling PSYCHIATRIC Depression Anxiety Suicide Complusive behavior Schizophrenia Mood swings Bipolar disorder FAMILY HISTORY Bleeding problems Heart disease High blood pressure Diabetes Problems with anesthesia Osteoporosis 5

6 Please list any medical conditions that you may have that were not listed above: SECTION #5 PROCEDURE RISKS Y N Have you had or been exposed to any blood borne diseases such as hepatitis or AIDS? Have you ever used recreational drugs? Do you take antibiotics before dental procedures because of your heart? Do you take aspirin, Motrin or other pain relievers on a regular basis? If yes, please list: Do you take Lovenox, Coumadin or Plavix? Have you had problems with anesthesia in the past? If yes, please describe: SECTION #6 EDUCATION NEEDS Y N Do you perform regular monthly breast self-examinations? Do you feel comfortable with your performance of a regular examination of your breasts? Would you like more information on Breast Self Examination? Do you understand that it is recommended you have a yearly breast exam by a health professional? Do you understand that some breast cancers are very small and may not be felt by your health professional or seen by any imaging tests (mammography, ultrasound, etc.) because they may look and feel like normal breast tissue? Do you understand that a mammogram is currently the single best test for detecting breast cancer? Did you know that the risk to your health from a mammogram is statistically negligible? This is because the amount of radiation from a mammogram is approximately equal to that of an airplane flight across the country? Would you like more information on radiation risk? Do you understand that participation in a breast cancer screening routine consisting of mammogram, physical exam and breast self-exam is the best way to detect a breast cancer, although it may not detect all breast cancers when they are early? Do you understand that for certain high-risk patients there are now methods proven to reduce the risk of breast cancer? Would you like more information about risk-reduction for high-risk patients? Do you understand that for certain high-risk patients genetic counseling is available to see if you and your family carry a specific gene, making you more likely to get breast cancer? Would you like more information on genetic counseling? 6

7 Reason for coming to the Center: R L Both 1. Abnormal mammogram, ultrasound or MRI 2. YOU feel a lump in your breast 3. Your DOCTOR feels a lump in your breast If Yes to 2 or 3, then: When did you first notice the lump? weeks / months / yrs ago How has it changed since you first noticed it? BIGGER SMALLER NO CHANGE Is the lump painful/sore? YES NO Have you has something like this in the past? YES NO How big is the lump? BB Pea Grape Golf ball Orange R L Both 4. Breast Pain If yes, then: WHOLE BREAST or SPECIFIC AREA Is it worse with your menstrual cycle? YES NO Is it constant? YES NO Do you take OTC or Rx pain medicine for the pain? YES NO o Does the medicine help? YES NO o Name of the medicine: Do you consume caffeine? YES NO o Coffee: cups/day o Chocolate: o Tea: cups/day How long have you had the pain? weeks / months / years R L Both 5. Nipple discharge If yes, then: SPONTANEOUS or NON-SPONTANEOUS (spontaneous = you must stimulate your nipple to produce discharge) (non-spontaneous = discharge appears without stimulating your nipples) ONE DUCT or MULTIPLE DUCTS What does the discharge look like? BLOODY CLEAR MILKY GREEN/BROWN/YELLOW How long have you had the discharge? R L Both 6. Breast skin changes If yes, then: Redness YES NO Itching YES NO Scaling YES NO Thickening YES NO Dimpling YES NO Heaviness YES NO Swelling YES NO R L Both 7. OTHER Describe: 7

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