MAMMOGRAPHY HISTORY WORKSHEET















YesNo






YesNo




YesNo






YesNo

RTLT



YesNo

Mother



Grandmother



Aunt



Sister



Daughter



Cousin




YesNo








YesNo


YesNo





YesNo


YesNo


YesNo




Estrogen

Progesterone

Birth Control Pills



YesNo

Mastectomy

RT

LT



Lumpectomy

RT

LT



Radiation

RT

LT



Chemotherapy

YesNo

Implants

RT

LT



Reduction

RT

LT



Biopsy

RT

LT








[/wr_row espanolfarmacia.net]