Breast Imaging Patient Information "*" indicates required fields 09/08/2024Name* First Last Email* MRN* Age* Weight Referring Physician Sex* Male Female PATIENT HISTORYHave you had a mammogram before? Yes No When and where? Have you had any other breast imaging? Yes No When and where? Are you having any of the following problems? (Check all that apply)None (Check one or both) None (Check one or both) None (Positions)* Left Right Lump Lump Lump – L/R* Left Right How long Nipple discharge Nipple discharge Nipple Discharge – L/R* Left Right How long? Color? Pain Pain Pain – L/R* Left Right How long? Breast implant problem Breast implant problem Breast implant problems – L/R* Left Right Describe Nipple inversion Nipple inversion Nipple inversion – L/R* Left Right Nipple inversion – Always/New* Always New Other Other Nipple inversion – L/R* Left Right Describe below*Do you have breast implants? Yes No Breast implants – L/R* Left Right Have you ever been diagnosed with breast cancer? Yes No Breast cancer- L/R* Left Right Have you ever had breast surgery (biopsy, reduction / lift)? Yes No When? Breast cancer- L/R* Left Right Are you pregnant now? Yes No Are you taking hormone medication? Yes No How long? What type? Do you have a family history of breast cancer? Yes No Mother Mother Age Diagnosis Sister Sister Age Diagnosis Daughter Daughter Age Diagnosis It is important that I continue monthly breast self-exams according to the American Cancer Society guidelines. I also realize that a visit to my physician for a physical examination of my breasts is an important part of my routine breast screening check-up.