( Label) 1. Main reason for this visit: 2. Who referred you to our office: 3. Please list any treating physicians: 4. Age: Height: Weight: Bra Size (if female): BREAST HISTORY 1. Do you perform breast self-examinations? o If so, how often? 2. Are you comfortable performing breast self-examinations? If no, why? 3. Have you noticed any lump, nipple discharge, skin or nipple rash, indentation, pain or other change? If yes, please explain: 4. Have you ever been diagnosedd with breast cancer? BREAST IMAGING 1. Do you undergo regular mammogram exams? often? o If so, how 2. When was your last mammogram? What facility? 3. When was your last ultrasound? What facility? 4. When was your last MRI? What facility? 5. Other breast imaging: _ RISK ASSESSMENT 1. Have any 1 st degreee relatives (mother, sister, daughter) been diagnosed with breast cancer? If yes, which relative, and what age were they diagnosed? 2. Have any 1 st degreee relatives (mother, sister, daughter) been diagnosed with ovarian cancer? If yes, which relative, and what age were they diagnosed? 3. Have you ever had chest radiation with the exceptionn of breast cancer treatment (for example Hodgkin s Lymphoma) )? If yes, what was the diagnosis, how old were you? 4. Have you had any other type of cancer? o If yes, please provide details (type, age at diagnosis, treatment): 5. Have you or any relatives been tested for or diagnosed with a genetic mutation (such as BRCA 1/2)? If yes, please providee details: Page 1 of o 6
( Label) GYNECOLOGIC HISTORY (if male, pleasee skip to next section) 1. How old were you at menarchee (first period)? 2. When was your last period? 3. If you are having periods, are they regular? Please describe: 4. Is there a possibility that you may be pregnant? t Sure 5. How many times have you been pregnant? How many children do you have?? How old were you when you had your first child?? 6. Did you breast feed? s If yes, for how long? Did you have any difficulties breast feeding? 7. Have you had a hysterectomy (removal of the uterus)? If yes, when and why? 8. Have you had your ovaries removed (one or both)? If yes, when and why? 9. Do you currently or have you used birth control pills, a hormone-secreting IUD, or hormone replacement therapy (estrogen, progesteron ne, testosterone, DHEA) including bio-identical hormones? If yes, please provide details (type, age, how many years): 10. When was your last pap and pelvic exam? Were the results normal? OTHER MEDICAL HISTORY & REVIEW OF SYSTEMS Medical History Please list past and current conditions (diabetes, hypertension, etc.) Condition Treating Physician 1. Do you have a pacemaker? 2. Have you ever had a colonoscopy? o If yes, was it normal? Current Medications (include dose/amou nt per day) Medication Dose/Frequency Prescribing Physician Page 2 of o 6
( Label) Allergies & Medication Reactions (medications, iodine, shellfish, contrast dye, latex, etc.) Allergy/Medication Reaction Surgical History Please list all surgeriess (include breast biopsies, implants, or aspirations) Surgery Physician/Location Pathology Results (if any) System Review Please note any persistent symptoms, pastt problems, or concerns: General Fevers Night sweats Chills Weight gain or loss Chronic fatigue Stress Pain Genitourinary Frequent urination Night time urinationn Burning or painful urination Blood inn urine Kidney stones Sexuallyy transmitted disease Changee in sexual function/interest Uterine or ovarian tumors Irregular or painful menstrual periods Uterine bleeding after menopause Prostatee enlargement or other problem Skin Hives or itching Rash or eczema New / changing mole, other skin lesion n healing wound or ulcer Musculoskeletal Joint stiffness, pain or swelling Muscle pain, cramping, weakness Injuries or joint fractures Hand orr arm swelling Bone pain Back pain Page 3 of o 6
( Label) Eyes, Ears, se and Throat Eye diseasee or injury Glasses or contact lenses Change in vision, blurry or double vision Change in hearing se bleeds, bleeding gums Sinus problems Voice changes, frequent sore throat Psychiatric Depression Anxiety,, nervousness Hallucinations Paranoia Memoryy loss, confusion Changee In sleep patterns o Respiratory Shortness of breath Cough Wheezing / asthma n healing wound or ulcer Neurological Faintingg Convulsions, seizures Headaches Changee in memory, concentration Numbness, tingling, weakness, paralysis Cardiovascular Chest pain or palpitations Shortness of breath when lying down Difficulty walking 2 blocks Swelling of hands, feet, ankles Blood clots Heart murmur Hematologic Anemia Excessive bleeding Abnormal bruising or bleeding Swollenn lymph nodes (glands) o Gastrointestinal Heartburn, reflux Black or bloody stool Constipation, diarrhea, change in stools Nausea, vomiting Change in appetite Endocrine Excessive thirst or urination Intolerance to heatt / cold Thyroid problems o Page 4 of o 6
Immunology/Allergy Frequent cold or flu Environmental or seasonal allergies ( Label) o FAMILY HISTORY Relative Current age, if living Age at death, if deceased Medical Problems History of cancer, type, treatment Age at cancer diagnosis SOCIAL HISTORY / LIFESTYLE E Demographics: 1. What do you consider to be your race / ethnicity? Please check all that apply: Ashkenazi Jewish American Indian, Aleutian, Eskimo Spanish / Hispanic / Latina Armenian African American Middle Eastern East Asian / Pacific Islander Russian European (including German, Dutch, Polish, Italian, French, Irish) Other: t Known 2. Marital Status: Single Married Domestic Partner Separated Divorce ed Widowed 3. Does anyone live at home with you? o If yes, please list: 4. Highest level of education: Graduate / Professional school Some college or Associate degree Other school beyond high school College degree High school diploma / GED Some high school Other: 5. What is your current occupation? 6. How many hours / week do you work? _ Page 5 of o 6
( Label) 7. Do you exercise at all? If yes, how frequently? less than one hr / week 1-3 hrs / week more than 4 hrs / week If yes, what intensity? low moderate high What type(s) of exercise? 8. How is your overall diet and are you on a special diet? (fairly healthy, portions too large, high sugar intake, high processed food intake, etc.) 9. Do you consume caffeine? How much/what type? 10. Which best describes your current alcohol use? Never Rare (few drinks per year) Few drinks per month Few drinks per week At least one drink most days 11. Do you have a history of alcohol abuse? o 12. Have you ever smoked? If yes, please describe (current, past, how manyy packs, age): 13. Have you ever used recreational drugs? o If yes, please describe (current, past, type, age) ):_ The information provided in this questionnai re is true and complete to the best of my knowledge. I understand that the accuracy of the information I have provided is important to my physician and my healthcare team in order to develop an individualized care plan for me. or Representat tive Signature Print Name Relationship to Interpreter (if applicable) Interpreter ID # Physician Signature Page 6 of o 6