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Women'S Health Center Form

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Women’s Health Center

3101 Shipper’s Road, Suite 106, Vestal, NY.

Date: ____________ Patient Name: _________________________________ DOB: ____________

Age at your first menstrual period: _________ When was your last menstrual period?: _______________

Are you post-menopausal? ☐NO ☐YES

If yes: How old were you when you stopped having periods? ______

Has your uterus been removed (a hysterectomy)? ☐NO ☐YES At what age? ________

Have your ovaries been removed? ☐NO ☐NOT SURE ☐YES

At what age? ________

Have you ever been pregnant? ☐NO ☐YES

If yes: How many times have you been pregnant? ______

How many children have you delivered? _______

Your age when your first child was born? ______

Have you ever been on infertility drugs or treatments? ☐NO

☐NOT SURE

☐YES

Are you a DES baby or have you taken DES?

☐NOT SURE

☐NO

☐YES

Have you ever taken hormone replacement therapy (HRT)? ☐NO ☐YES

If yes: For how many years? ____

Are you still taking it? ☐NO ☐YES

How long ago did you stop? _____________

Have you ever taken Tamoxifen? ☐NO ☐YES

If yes: For how many years? _______

Have you ever taken Roloxifene (Evisto)? ☐NO ☐YES

If yes: For how many years? _______

Have you ever had a breast biopsy? ☐NO ☐YES

If yes: How many? _______

Did any biopsy show atypical hyperplasia? ☐NO

☐NOT SURE

☐YES

Did any biopsy show LCIS (lobular carcinoma in situ) ☐NO

☐NOT SURE

☐YES

FAMILY MEMBER

AGE AT DIAGNOSIS

BREAST AND OVARIAN CANCER

SELF

Y N Breast cancer (personal/family)

Y N Ovarian cancer (personal/family)

Y N Uterine cancer (personal/family)

Y N Male breast cancer

Y N Prostate cancer

Y N Pancreatic cancer (personal/family)

Y N Ashkenazi Jewish, Hungarian, Swedish,

Icelandic, French Canadian, Caribbean

ancestry.

Y N Melanomas (personal/family)

Y N Family member or self with BRCA

gene?

Y N Have you or any member of your family ever been tested for hereditary risk of cancer?

If yes, please explain: ______________________________________________________________________

Patient Signature:

Date:

_______________________________

____________________

Women'S Health Center Form

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