Breast Patient Assessment

Patient Name:
Date:

What type of breast problem has led to your evaluation today?

Have you noticed any masses in your breasts?

yes no

If yes, please describe these changes:

Have you noticed any nipple drainage or retraction?
Have you experienced any pain or tenderness in your breasts?
When was your most recent mammorgram performed?
When was your last breast exam by a physician?
What was your age at the onset of your menstrual period?
What was the date of your last menstrual period?
What was your age at the time of your first pregnancy?
How many full term pregnancies have you had?
Did you breast feed your children?
If yes, please list duration:
Have you undergone any previous breast surgeries?

If yes, please list the type, date of procedure and outcome:

Have you ever been diagnosed with fibrocystic breast disease?

Do you have a history of breast cysts?

If yes, have you ever undergone drainage of these cysts?

Do you have a history of breast abscesses or mastitis while lactating?

What was your age at the time of menopause?

Have you ever taken birth control pills in the past?

If yes, please list age and duration of usage:

Have you ever taken hormone replacement therapy?

If yes, please list age and duration of usage:

Do you have a family history of breast cancer?

If yes, list their relation to you and their age at diagnosis

Do you have any history of any trauma or injury to the breast?

If yes, please describe

Do you have a history of radiation therapy to the chest wall?

Do you know the technique of self breast exam?

If yes, how often do you perform a self breast exam?