Breast Magnetic Resonance Imaging Information Form Page 2
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2Form #8888 (11/15) Page 8 of 8
you had radiation therapy to the breast?
Have
Yes no
Have you had chemotherapy? Yes no
if yes, which side? Right Left
if yes, what year? __________________
What year? ______________
When was your last mammogram? ___________________
When was your last breast MRi? ________
any mammograms done outside of Munson?
Yes no
any MRis done outside
if yes, where and when? _____________________________
of Munson?
Yes no
Diagram any scars and findings
¢
Scar
Palpable Lump
Skin Lesion/Mole
Pain
thickening
Comments:
REGARDING BREAST IMPLANTS
What type of implants do you currently have?
Silicone
Saline
Dual Lumen
Other (type) _________________________________
i don’t know
When were your current implants placed (year)? ___________________________
Have you had previous implants?
Yes no
What type of implants have you had in the past?
Silicone
Saline
Dual Lumen
Other (type) _________________________________
i don’t know
Have you had a prior ruptured implant?
Yes no
When? _______________ Was it replaced? Yes no
if yes, when (year)? _______________
Why are we doing the breast MRi at this time (what symptoms do you have)?
Patient iD LabeL
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