Breast Magnetic Resonance Imaging Information Form

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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

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