Elements marked * are required

 Reason for Visit *

 Referring Doctor

 Primary Care Doctor

 Are you planning to bring anyone to your visits? If so, name/relationship:

Have you ever had any breast problems? *   Yes      No   
If yes, please describe (cancer, pain, nipple discharge, abscess, cysts, other):

 Have you ever had a breast biopsy?  *   Yes    No   

 

Where? 

 

 If yes, Results     Normal/Benign     Hyperplasia (not atypia)     Atypical hyperplasia     Lobular Carcinoma in Situ (LCIS)     Unknown     Other

If you selected Other, please include details

Have you had any breast surgery?  *   Yes    No   

 Year

  Type of surgery

 Where?

  Reason

 Have you ever had radiation treatment to your chest area and/or to a breast?  *     Yes     No 

 Bra Size *

 Height *

 Weight *

 Headaches
 Stroke
 Thyroid problem
 Diabetes (Type I or II)
 Atrial Fibrillation
 Congestive Heart Failure
 Heart disease/Heart attack
 High blood pressure
 High cholesterol

 Asthma
 COPD/emphysema
 Sleep apnea
 Bleeding Disorders/Anemia
 Kidney problems
 Liver problems
 Hepatitis
 HIV/AIDS
 Alcoholism

Arthritis/Gout
Epilepsy/Seizures
 Testicular mass/Tumor
 Lupus/SLE
 Collagen vascular disease
 Scleroderma
 Cancer (type)

 Please list any additional medical problems and/or surgeries you have had

 Please list all known drug allergies

Have you ever taken any of the following?     *    Yes     No   

(Mark all that apply)

 Estrogen       Growth hormones      Steroids        Herbal supplements  

Do you currently take any of the following?   *       Yes     No   

(Mark all that apply)

 Aspirin     Coumadin/Warfarin     Eliquis     Xarelto     Plavix     Other    

Have you ever had any genetic testing?    *    Yes     No   

 Year

  Results

Have any family members had testing?    *    Yes     No   

 Who and results?

Are you of Ashkenazi Jewish descent?  *   Yes    No   

 Mother or father's side?

 Age at first menstrual cycle

 Last menstrual cycle (if applicable)

 

# Pregnancies

 

# Births

 

Age at first live birth

 

 

Did you breast feed your child(ren)?     

 Yes      No      NA

Have you gone through menopause?

 Yes        No      Age 

Have you had a hysterectomy?

   Yes      No   

Have you had your ovaries removed?

 Yes      No      Unknown    

Have you ever taken birth control pills?       Yes       No 

Still using?      Yes      No   

If yes, what medication?

If yes, number of years

Have you ever taken hormone therapy?   

    Yes      No    

Still using?    

   Yes      No   

If stopped, how many years ago?
If yes, what medication?
Number of years taken

 

 

 Never     Socially   Daily (# drinks/day)  

# cigarettes/day:      # of years 

Elements marked * are required

Please list all medications that you are currently taking.
Include all over-the-counter medicines, vitamins and herbal supplements.
 

 Please list all known drug allergies

Please bring all the medication bottles with you to your appointment so we can do a thorough review of your medications.