Comprehensive Breast Care Center Patient History Questionnaire

Transcription

1 Comprehensive Breast Care Center Patient History Questionnaire Date of Birth Age Sex F M Height Weight HISTORY OF PRESENT ILLNESS: Reason for today s visit? Any other NEW breast concerns today? BREAST HISTORY: Date of your last clinical breast exam by a health care provider: Have you ever had any of the following? Mammogram Yes No If Yes, WHEN was the last one? WHERE was it done? Breast MRI Yes No When? WHERE? Breast Ultrasound Yes No When? WHERE? Breast Biopsy Yes No If Yes, WHEN Which Breast? Left Right Result WHEN Which Breast? Left Right Result Cyst Aspiration Yes No If Yes, WHEN Which Breast? Left Right Result Injury to Breast Yes No If Yes, WHEN Which Breast? Left Right Result Breast Cancer Yes No If Yes, Right WHEN Left WHEN Both WHEN IF you have had Breast Cancer, what treatment(s) did you receive? Surgery? Yes No Mastectomy? Left Right Lumpectomy? Left Right Chemotherapy? Yes No Radiation? Yes No Other Breast Cancer Treatment? Other Breast Surgery? Implants? Yes No Breast Reduction? Yes No Other Breast History/Procedures?

2 GYNECOLOGIC/HORMONAL HISTORY: Females Only Age when you began your periods: If still having, First day of your last period: / / How may time have you been pregnant? How many children have you had? How old were you when you first child was born? Did you breastfeed any of your children? Yes No If yes, Total # of months you nursed: Are you pregnant now? Yes No Are you nursing now? Yes No Have you used birth control pills, patches or rings? Yes No If yes, age started Total of years used? Have you had a hysterectomy? Yes No If yes, what age? For what reason? Do you still have you ovaries? Both One None Age at natural menopause: Have you had any treatments to help you get pregnant? Yes No Have you ever been on these hormones after menopause? Estrogen? Yes No Progesterone? Yes No On now? Yes No If ever used, age started: If no longer taking, age stopped: Allergic to any medications? Yes No If yes, please list below: ALLERGIES: Are you allergic to: What happens when you take it? What happens? Latex? Yes No X-Ray dye? Yes No Do you have other allergies such as food or environmental Yes No

3 CURRENT MEDICATIONS: Please include prescription and over the counter meds supplements & vitamins Medication (Dose and how often) Taking For? Medication (Dose and how often) Taking For? Other Medications: MEDICAL HISTORY: Please list current and important past medical problems Medical Problem When Diagnosed Treating Provider SURGERY HISTORY: Please list any surgeries that you have had PROCEDURE Date Treating Provider and Hospital

4 FAMILY HISTORY OF CANCER: Please list all known cancers in in your close family members (Includes mother, father, sister, brothers, children, grandparents, aunts, uncles, first cousins and great-aunts, great-uncles, and great-grandparents) MOTHER S SIDE FATHER S SIDE Relationship Type of Cancer Age at Diagnosis Relationship Type of Cancer Age at Diagnosis YOUR SIBLINGS YOUR CHILDREN Other Non-Cancer Medical Problems in your Family: Have you ever had genetic counseling or testing for cancer? Yes No If yes when and where? If Tested, Results? Are you of Ashkenazi (Eastern European) Jewish descent? Yes No Don t Know Please circle if you are of: French Canadian Swedish Icelandic Hungarian or Dutch descent SOCIAL HISTORY: What is your occupation? (If retired, list previous occupation) Marital status Single Married Widowed Divorced Do you exercise Yes No Type of Exercise: Hours per week: DO you smoke now? Yes No Numbers of cigs per day How many years: Did you ever smoke? Yes No Packs per day How many years Year quit Do you drink alcohol? Yes No Number of drinks per week Do you ever feel physically or emotionally threatened by another person? Yes No Do you have any difficulties performing your normal activities of daily living? Yes No Current Pain? Yes No Severity Scale (circle appropriate number) No pain Worst Pain If Yes, WHERE is your pain? _

5 How strong is your support system of friends and/or family? (Circle number below) Very Weak Somewhat Weak Neither weak or strong Somewhat Strong Very Strong REVIEW OF SYSTEMS: Please check all that apply to you Constitution: Unexplained weight gain Unexplained weight loss Unexplained fever or chills Fatigue/weakness Sweats or night sweats Appetite change Eyes; Vision loss Cataracts Glaucoma Ears/nose/Throat: Hearing loss Ringing in ears Nosebleeds Frequent sinus problems Hoarseness Dental problems Sore Throat Respiratory: Shortness of breath at rest Shortness of breath with Wheezing or Asthma history Persistent Cough activity Blood in sputum Cardiovascular: Chest pain/angina Swelling in feet or ankles Heart murmur Rapid or irregular Pain in calf with walking Rheumatic fever history Mitral valve prolapse Pacemaker Gastrointestinal: Abdominal pain Heartburn/Reflux Nausea or vomiting Jaundice Blood in stool Constipation or diarrhea Difficulty or pain with History of liver or Hemorrhoids swallowing gallbladder disease Genitourinary: Female or Male Difficulty controlling Frequent or nighttime Sexually transmitted bladder urination infections Pain with urination Blood in urine HIV/AIDS Female Only Urinary urgency or Endometriosis Vaginal discharge incontinence Painful intercourse Uterine fibroids Ovarian cysts Vaginal dryness Hot Flashes Male Only Enlarged prostate or Testicular mass or Hesitancy of urinary other prostate problems abnormality stream Musculoskeletal: Painful joints or muscles Back pain History of fracture Arthritis Skin/Integument: Rashes Hives/itching Hair loss or thinning Eczema or psoriasis Change in mole Neurologic: Headaches Seizures Dizziness Confusion Forgetfulness or memory Numbness or weakness loss in extremity Hematologic/Lymphatic Bruise easily Anemia Bleeding problems and Immunologic: Blood clots Swollen glands Recurrent infections Psychiatric: Sleep disturbances Depression/sadness Anxiety/worry Suicidal thoughts Stress Homicidal thoughts Loss of sexual desire Signature of patient or person completing this form: Revised ard Date: