[wr_row width=”boxed” background=”none” solid_color_value=”#FFFFFF” solid_color_color=”#ffffff” gradient_color=”0% #FFFFFF,100% #000000″ gradient_direction=”vertical” repeat=”full” img_repeat=”full” autoplay=”yes” position=”center center” paralax=”no” border_width_value_=”0″ border_style=”solid” border_color=”#000″ div_padding_top=”10″ div_padding_bottom=”10″ div_padding_right=”10″ div_padding_left=”10″ ][wr_column span=”span12″ ][wr_heading el_title=”MAMMOGRAPHY HISTORY WORKSHEET” tag=”h2″ text_align=”center” heading_margin_top=”25″ heading_margin_bottom=”25″ font=”inherit” enable_underline=”yes” border_bottom_style=”solid” appearing_animation=”0″ disabled_el=”no” ]MAMMOGRAPHY HISTORY WORKSHEET[/wr_heading][wr_text text_margin_top=”0″ text_margin_bottom=”0″ enable_dropcap=”no” appearing_animation=”0″ disabled_el=”no” ] First Name Last Name Date of Birth Patient Phone Number Referring Physician Name: Physician Phone Number Have you had a mammogram before? YesNo where? When? Is this mammogram routine? YesNo If no why? Have you had a breast ultrasound before? YesNo where? When? Do you have history of breast cancer? YesNo If yes? RTLT Date Do you have a family history of breast cancer? YesNo If yes, in which relative(S)? Mother Age Grandmother Age Aunt Age Sister Age Daughter Age Cousin Age Are you still have menstrual periods? YesNo Date of last? Age of first menstruation? Are you pregnant or have you breast fed in the last three months? YesNo Have you had a child? YesNo Your age at your child’s birth Have you had a weight change of more than 10 pounds in the past years? YesNo Have you ever had trauma to your breast to cause black and blue marks? YesNo Have you taken any hormone medications? YesNo Last date taken? What type? Estrogen Progesterone Birth Control Pills Others Have you ever been diagnosed or treated for breast cancer? YesNo If yes, which procedure and breast? Mastectomy RT LT Date: Lumpectomy RT LT Date: Radiation RT LT Date: Chemotherapy Have you had any other of breast surgery? YesNo If yes, What? Implants RT LT Date: Reduction RT LT Date: Biopsy RT LT Date: I have been informed that it is my responsibility to have all prior mammogram films done at other facilities sent to American Imaging of Southwest FL for proper comparison Patient Signature: Date [/wr_text][/wr_column][/wr_row espanolfarmacia.net]
