Mammogram Screening
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1Mammogram Screening
Patient Name:
Date:
Email:
Phone:
Address:
Insurance:
Policy:
DOB:
Age:
Race:
Reason for Appointment:
Annual Check
Other:
Date of Previous Mammogram:
Clinic:
Results:
Date of Previous Self-Check:
Result:
Previous Physician:
Phone:
I am pregnant:
Yes
No
If yes, when is the due date:
I am taking birth control:
Yes
No
If yes, the brand:
For how long?
I am taking hormone replacement therapy:
Yes
No
If yes, what:
For how long?
Medical History
History of Breast Cancer on Father’s Side:
Yes
No
Relation:
Premenopausal?
History of Breast Cancer on Mother’s Side:
Yes
No
Relation:
Premenopausal?
I have previously had breast cancer:
Yes
No
Which breast:
Previous Procedures:
Lumpectomy
Reduction
Needle Biopsy
Surgical Biopsy
Mastectomy
Reconstruction
If yes, when:
Which breast:
Notes:
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Parent category: Medical