Mammography Pre-Appointment Patient Questionnaire

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Fields marked * are required
  Name:*
  Email:*
  Date of Examination:*
  Day time phone:*
  Date of birth:*
  Address:*
  Referring Physician:*
     
1. Is today's exam routine?
  If not, what is the reason for today's study?
 
     
2. Have you ever had a mammogram?
  If yes, date of last?
     
3. Have you had any previous breast surgeries or biopsies?
 
Type Right Left Date(s) Radiation?
Lumpectomy (cancer)
Mastectomy (cancer)
 
Needle Biopsy
 
Lump Removal
 
Cyst Drainage
 
Breast Reduction
 
Implants
 
Other
 
     
4. Do you have any family history of breast cancer?
  If yes, what is your relationship(s):
  Age of Relative when Diagnosed:
   
5. Do you, personally, have a history of any type of cancer
other than breast?
  If yes, what type(s)?
  Approximate age diagnosed?
     
6. Have you ever had injury severe enough to bruise your breasts? Yes No
  If yes, when? Right Left
     
7. Are you or have you ever used hormones? Yes No
(i.e. estrogen, premarin, provera, tamoxifen, vaginal creams, etc.)
  Which Type(s)?
  Date(s) started
  Date(s) ended
     
8. Have you ever had a hysterectomy? Yes No
  If yes, what age?
  Ovaries left in? Yes No
     
9. At what age did you start menstruating?
  When was your last period?
     
10. What was your age at first pregnancy?
  How many children do you have?
     
11. Did you breast feed your children? Yes No
  If yes, how long? In the last 6 months? Yes No
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