Element Medical Imaging


Breast Health History Form

 
Exam History
Reason for today's exam

Procedure



Has your weight changed since your last mammogram?


Current Symptoms
Are you having any NEW problems with your breasts?

Are you currently breastfeeding?

Are you currently pregnant or trying to get pregnant?

History of Breast Cancer
Do you have a family history (mother, father, sister, daughter) of breast cancer?

Do YOU have a BRCA1 or 2 mutation or another similar genetic syndrome?

Have YOU been diagnosed with BREAST cancer?

Have YOU ever had a biopsy with atypical hyperplasia (ADH/ALH)?

Have YOU been diagnosed with ANY OTHER type of cancer?

Breast Procedure History
Have you had any procedures or breast surgery?

Risk Factors/Gail Risk Model Calculator
Age of first menstrual period


Have you ever been pregnant?    

Are you


Have you taken hormone replacement therapy (HRT)?

Have you had a hysterectomy? (removal of uterus)

Have you had an oophorectomy (removal of ovaries)?

What is your race?





What is your sub race/ethnicity if applicable?





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