Patient History Questionnaire Comprehensive Breast Care Center

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1 Patient History Questionnaire Comprehensive Breast Care Center Patient Name of birth Age Occupation Today s Height Weight Primary Care Physician: OB/ GYN: Referring Physician: Who else may we send a medical consult letter to? Please indicate here: HISTORY OF PRESENT ILLNESS What is the reason for today s visit? Please check all that that apply: I feel a lump in my breast? If yes, which breast? Right Left If yes, present for how long? Is the lump painful? Yes No Does the lump change in size with your periods? Yes No I have had a Mammogram in the past Mammogram was performed at. Approximate date of most recent mammogram. I have been told I ve had an abnormal mammogram. Other breast problems include PERSONAL BREAST HISTORY: Have you ever had: Breast cancer? If so, when _ Which breast? _ How was it treated? A breast biopsy? _ If so, when Which breast? Injury to your breasts? If so, when _ A needle aspiration to remove fluid from a cyst? Which breast? 1

2 Nipple discharge? If so, when Which breast? PATIENT NAME _ TODAY S DATE _ HORMONAL HISTORY: If menstruating, date of your last period (first day of): Your age when you began your periods Age when you stopped (if you have) _ Have you had a hysterectomy? If so at what age? and for what reason _ Do you still have your ovaries? How many times have you been pregnant? How many children do you have? _ How old were you when your first child was born? _ Are you pregnant now?_ Have you ever taken Hormone Replacement Therapy? _ If so, when and for how long? FAMILY HISTORY (please list all relatives who have had breast cancer) Relative Mother s or Age at diagnosis One or both breasts If living, age If deceased, age at death Father s side Please list other cancers in your family (colon, ovarian, uterine, lung, etc), who had cancer, and at what age it Was diagnosed: Relative Mother s or Father s side Site of cancer Age at diagnosis PAST AND CURRENT MEDICAL PROBLEMS:

3 6. 7. PATIENT NAME _ TODAY S DATE _ HOSPITAL ADMISSIONS OR SURGERIES (please list): Illness or operation CURRENT MEDICATIONS, DOSAGES, FREQUENCY AND REASON (include over the counter & herbals) Medication Dose Frequency Reason to take ALLERGIES :( to medications): MEDICATION What happens? Other substances 3

4 PATIENT NAME _ TODAY S DATE _ SOCIAL HISTORY: Marital Status Single Married Widowed Divorced Do you exercise? Yes No Type of exercise: Times per Week: Do you smoke Yes No Numbers of cigarettes per day Did you smoke? Yes No Packs per day how many years? _ What year did you quit? Do you drink alcohol? Yes No Number of drinks per week Do you ever feel you are physically or emotionally threatened by any person? Yes No Do you have any difficulties performing your normal activities of daily living? Yes No Current pain: No Yes Severity Scale: (circle) REVIEW OF SYSTEMS (CHECK ALL THAT APPLY) Constitutional: Unexplained Weight Appetite loss Unexplained fever/ Loss/gain chills Fatigue Dizziness Other Eyes: Vision problems Frequent headaches Other Ears / Nose / Throat Hearing problems Ringing in the ears Bloody nose Other Cardiovascular: Chest pain High cholesterol Swelling Loss of consciousness Pacemaker Other Gastrointestinal: Indigestion Heartburn Nausea / vomiting Abdominal Pain Constipation Diarrhea Bloody Stools Other Genitourinary: Difficult urination Frequent urination Bloody urine Frequent nighttime Discharge Uterine fibroids urination Endometriosis Ovarian cysts Other Musculoskeletal: Painful joints Back pain Difficulty in performing normal activities Other Integument / Skin: Rashes Hives Other 4

5 Neurologic: Seizures Speech problems Tingling of extremities Other Respiratory: Shortness of breath wheezing Cough Other PATIENT NAME _ TODAY S DATE _ Psychiatric: Depression Anxiety High stress Other Endocrine: Breast Masses High blood sugar Steroid use Other Hematologic: Bruise easily Anemia Bleeding disorder Other Allergies: Seasonal Allergies Other Patient signature/ or person completing these forms Today s : I have reviewed the patient history questionnaire.. 5

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