Breast Form - New - Atlanta Plastic & Reconstructive Specialists

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ATLANTA PLASTIC & RECONSTRUCTIVE SPECIALISTS, LLC.
Specific Women’s History
Name____________________________
# Pregnancies _______
# of Live births_____
Age at 1
st
delivery _______
Age at time of 1
st
period__________
Date of last period________________
If you have or have had any of the following please check and describe:
Yes
No
Comments
Estrogen/Birth Control Pills
( )
( )
__________________
Fertility Meds
( )
( )
__________________
Regular Periods
( )
( )
__________________
Menopause
( )
( )
__________________
Complications during birth
( )
( )
__________________
Fibrocystic breasts
( )
( )
__________________
Breast Lump
( )
( )
__________________
Nipple discharge
( )
( )
__________________
Pain in breast
( )
( )
__________________
Did you breast feed?
( )
( )
__________________
Family history of breast cancer
( )
( )
Who: _____________
When/Where/Results
Recent Mammogram
( )
( )
__________________
Breast Ultrasound
( )
( )
__________________
Breast MRI
( )
( )
__________________
Breast Biopsy
( )
( )
R
L
Date_________
Breast Cancer Diagnosis
( )
( )
R
L
Date_________
Lumpectomy
( )
( )
R
L
Date_________
Mastectomy
( )
( )
R
L
Date_________
Radiation Treatment
( )
( )
Dates: ______________________
Chemotherapy Treatment
( )
( )
Dates: ______________________
Breast Surgeon’s Name/Address____________________________________________________________
Oncologist’s Name/Address_______________________________________________________________

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