FORM # 8888 (11/15) Page 1 of 8
8888
BREAST MAGNETIC RESONANCE IMAGING INFORMATION FORM
Appointment Information:
Date _______________
arrive _______________
If you cannot make this appointment date and time, please phone us at least 24 hours in advance.
Mon. thru Fri. 8:00 a.m. to 5:00 p.m., please call (231) 935-2185 or (800) 468-6766 ext. 52185
Sat. and Sun. 7:30 a.m. to 7:00 p.m., please call (231) 935-7492
PLEASE PRINT
name ___________________________ MR # ______________ Wt. _______ DOb _______ age _______
Do you have any discharge from your breasts?
Yes no
Do you have any breast pain? Yes no
if yes, which one? Right Left Color ______________
if yes, which breast? Right Left
Do you have a breast lump?
Yes no
type of pain _______________________
if yes, which one? Right Left
Do you have a personal history of breast cancer? Yes no
Date of diagnosis ____________________
any relatives with a history of breast cancer?
Yes no
Have you been evaluated at a high risk or
if yes, who and at what age?
genetic clinic? Yes no
Mother
age ________
Where? _________________________
Sister
age ________
What is your risk? _____________ %
Grandmother
age ________
Please include a copy of your high risk report
Other _________________
age ________
are you still menstruating?
Yes no
Do you take birth control pills? Yes no
if yes, date of last menstrual period ____________
if yes, for how long? _________________
if no, year of last menstrual period _____________
are you currently taking estrogen replacement therapy?
Yes no
if yes, for how long? __________________________
Could you be pregnant?
Yes no
Have you had prior breast surgery?
Yes no
Have you had breast cancer? Yes no
If yes, what type?
Date
Which Side?
benign biopsy
________________
Right
Left
Lumpectomy
________________
Right
Left
Mastectomy
________________
Right
Left
Other ___________________
________________
Right
Left
Patient iD LabeL