Breast disease evaluation form

1. 1. Your Personal Identification Number or PIN:   If you have not a PIN, please click Here

2. Your Date of Birth:

3. Your Doctors Name and Address:

4. Ethnic background:

5. At what age did you have your first menstrual period?

6. How many times have you been pregnant? (Miscarriages & Abortions included):

7. How many living children have you delivered?

8. How old were you with your first pregnancy?

9. Did you breastfeed? YesNo

10. If yes, for how long?

11. If you do not have periods anymore, how old were you when you had your  the last period?

12. Has your uterus been removed?YesNo

13. If yes, at what age?

14. Did they remove your ovaries too? YesNo

15. Have you ever taken birth control pills? YesNo

16. If yes, how long were you on birth control pills?

17. Currently taking the following birth control medication YesNo

18. In the past took the following birth control medication.

19. Have you ever taken Premarin or other Estrogen, or hormones of any type? YesNo

20.   If yes, for how long?

21. Have you ever taken fertility drugs? YesNo

22. Do you do a monthly breast self-examination? YesNo

23. When was you last Pap smear?

24. Was it a normal test? NormalAbnormalBorderline

25. If not normal please send us the report  

26. Have you ever had a Mammogram? YesNo

27. If yes, what was the date of your last Mammogram?

28. Have you had an abnormal Mammogram? YesNo

29. If not normal, please send us the report 

30. Have you ever had a breast biopsy? YesNo

31. If yes, how many?

32. Did any biopsy show atypical hyperplasia? YesNo

33. Have you ever had nipple discharge?YesNo

34. If yes, of what color?

35. Did you ever have breast cancer? YesNo

36. If yes, what histological type?

37. If you can send us the histological report of your surgery or breast biopsy.

38. Did your doctors suggested any treatment to you? YesNo

39. If yes, which of the follow ones?

Observation   

Fine Needle Aspiration   

Core-Needle biopsy

Stereotactic Biopsy    

Excisional Biopsy      

  Wire Localization biopsy

Lumpectomy or Partial Mastectomy with Axillary Dissection

Lumpectomy or Partial Mastectomy and Sentinel Node Biopsy

Modified radical Mastectomy    

 Radical Mastectomy   

Simple Mastectomy 

Any radiation before or after surgery     

Any Chemotherapy Before or after Surgery 

Any Hormonal Treatment after Surgery or after Chemotherapy

40. Any other treatments? YesNo

41. If yes, described it or send us your treatment plan. 

42. Did you have ever had any other cancer? YesNo

43.  If yes, in what organ of your body?

44. Do you currently have a breast lump or mass? YesNo

45. If yes, how was it detected? Self Breast ExaminationMammogramUltrsoundDoctor's OfficeOther

46. Did you have any Ultrasound or Mammogram in the last 12 Months? YesNo

47. If yes,  send us the  reports of your mammograms

48. When did you last have your stool checked for blood?

49. What was the result? NegativePositive

50. Have you ever had a sigmoidoscopy?YesNo

51. Have you ever had a colonoscopy YesNo

52. If yes when and what were the findings?

53. Do you smoke? YesNo

54. If yes, how many years have you smoked?

55. How many packs per day?

56. Are you a former smoker? YesNo

57. If yes when did you quit?

58. Do you drink alcoholic beverages? YesNo

59. If yes, how many drinks per week?

60. What do you think is your risk of getting breast cancer?Very lowAverageSomewhat higher than averageMuch higher than average

61. How concerned are you about your risk of getting breast cancer?Not at allRarely worryOccasionally worryVery worriedWorry constantly

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