Patient Assessment Form (Radiologist)
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2Patient’s Name___________________________________________ Mammogram ID_______________________________________
Radiologist’s Name_______________________________________
Interpretation Date_____________________________________
Indication for Exam (check one)
Screening
Short interval follow-up of an abnormal mammogram
Additional work-up of abnormal mammogram
Evaluation of a breast problem
Type of Exam (check all that apply)
Diagnostic view (additional magnification, cone,
Standard screening views (1-3 views)
compression views)
Ultrasound
Other
Mammogram(s) used for comparison?
No
Yes (Please specify month and year) _______________
Tissue Density (that of denser breast)
Almost entirely fat
Heterogeneously dense
Scattered fibroglandular densities
Extremely dense
Assessment (per breast)
Both
Left
Right
0 - Incomplete: Need additional imaging evaluation
1 - Negative
2 - Benign
3 - Probably benign
4 - Suspicious
5 - Highly suggestive of malignancy
Most Significant Finding for Assessments 0,3,4 and 5
(check one)
A
B
C
D
Architectural
Both (Ca +
Calcification
Density
Distortion
Mass, Density
(one view only)
or a.d.)
F
M
N
S
Focal
Mass
Neodensity
Single Dilated Duct
Asymmetric
Densities
Recommendation (check all that apply)
Both
Left
Right
Normal interval follow-up
Additional views
Ultrasound
Short-term follow-up mammography
Fine needle aspiration (including cyst aspiration)
Core biopsy
Consider surgical biopsy
Clinical examination for further diagnostic evaluation
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