Form 274a - Take Charge! Breast And Cervical Cancer Screening Form printable pdf download

Take Charge! Breast and Cervical Cancer Screening Form

ODH Form No.274A

Chart ID #________________________________

Part 1: DEMOGRAPHICS

Facility name: _________________________ Facility site number: _________ Social security number: _____-____-_______

Age: ____

Last name: ___________________________

First name: ________________________

MI: ______ Maiden: _________________

DOB: _____/_____/______

Daytime phone #: ( _____ ) _______-_______

Address: ________________________________________ City: ______________ State: ____ Zip: ______

County: _______________

Race: White

 Black

 Asian

 American Indian

 Native Hawaiian

 Pacific Islander

 Eskimos

 Other  Unknown

Ethnicity: Hispanic

 Non-Hispanic

 Unknown

Are you currently employed?  Full time

 Part time

 None

Company name:________________________________ Address:_____________________

City:_________

State:_____

Zip: ______

Part 2: REFERRAL SOURCE

 Community Organization

 Health Department

 Family/Friend

 Health Fair

 Worksite

 Provider

 Flyer/Brochure/Poster

 Presentation

 Media

 Self

 Recall/Reminder

Part 3: HEALTH INFORMATION

Height: ________ Feet _______ Inches

Weight: _________ Pounds BMI: _______

Blood Pressure: ______Systolic/_____ Diastolic

Physical Activity information was provided?  Yes

 No

Nutrition information was provided?  Yes

 No

Date of last A1c test: ____________________

 Never

Date of last cholesterol test:______________  Never

Part 4: BREAST CANCER SCREENING INFORMATION

Client Reports Breast Symptoms?  Yes*  No  Unknown

(* Lump  Nipple Discharge  Pain  Skin Changes)

Prior Mammogram?  Yes

 No

 Unknown

Location:______________________________

Date: ______/______/___________

Part 5A: INDICATION FOR INITIAL MAMMOGRAM

 Cervical record only, breast services not done

 Routine screening mammogram

 Diagnostic referral (6 month follow-up, or patient only received CBE, or referral from outside)

 Refused

 Initial mammogram to evaluate symptoms, abnormal CBE or previous abnormal mammogram

 Unknown

Part 5B: CLINICIAL BREAST EXAM (CBE) INFORMATION

Part 5C: BREAST IMAGING

Facility name: ________________________________________

Referred for:  Screening Mammogram

 Diagnostic Mammogram

Date CBE performed: ______/______/____________

Mammography Type:  Film

 Digital

Paid by Take Charge! Program?  Yes

 No

 Unknown

Paid by Take Charge! Program?  Yes

 No

 Unknown

Facility name: ______________________________________________

Findings of CBE:

Date performed: ________/________/___________

 Benign Finding

Date results received: ________/________/__________

 Bloody or serous nipple discharge

Date client notified: ________/________/_____________

 Discrete palpable mass-suspicious for cancer

Results of mammogram:

 Discrete palpable mass (diagnosed benign)

 BI-RADS

0 (Assessment incomplete, needs additional views)

 Nipple or areolar scaliness

 BI-RADS

0 (Film comparison required)

 Normal

 BI-RADS

 Unsatisfactory

 Not done-normal CBE in past 12 months (attach records)

 BI-RADS

 Result pending

 Result unknown (presumed

 Not done-other unknown reason

 BI-RADS

 Refused

 BI-RADS

abnormal, mammogram from

 Skin dimpling or retraction

 BI-RADS

non Take Charge! facility)

Breast work-up planned:

Clinical Comments:

Please note: Handwritten notes are not entered in database

 Yes (needed or planned) (mark type of work-up below)

 Additional mammography views

 Biopsy

 CBE by consult

 Film comparison

 FNA

 Obtain definitive diagnosis

 Surgical consult

 Ultrasound

 Repeat mammogram immediately

 Other, List: _______________________________________

Short term follow up: _________________________ months

 No (Not needed) - Follow routine screening (1 year)

 No (Not needed) - Follow up in 2 years

 Unknown (not yet determined)

Form 1 of 2

ODH Form No. 274A

Revised June 2014

Form 274a - Take Charge! Breast And Cervical Cancer Screening Form

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