5007 Summerville Rd ● Phenix City, AL. 36867
Phone: 334-408-2854 ● Fax: 334-384-9274
www.2bridgeway.com
Mammography Department Worksheet
PATIENT NAME: ________________________
DATE:
_______________
DOB:
________________________
Accession #: _______________
Home Phone:
________________________
Account #: _______________
Work Phone:
________________________
Ref Phys:
_______________
1.
Was your last mammogram performed at Bridgeway Diagnostics
(circle) yes
If you answered no, list prior facility or city where you had your exam at:
_____________________________________________
How old were you when you gave birth to your first child? _____________
Is there any possibility you are pregnant now?
(circle)
yes
no
Do you still have a menstrual cycle?
(circle)
yes
no
Have you had a hysterectomy?
(circle)
yes
no
Have you gone through menopause?
(circle)
yes
no
Are you currently taking hormones or steroids?
(circle)
yes
no
Do you have a family history of Breast Cancer?
(circle)
yes
no
2.
3.
4.
5.
6.
7.
8.
If yes, please indicate whom:
9.
10.
no
_____mother ____sister(s) ____aunt(s) ____grandmother(s) ____cousin(s)
Previous Cancer? What kind? _______________________ When: _____________
Have you had any surgeries on your breast(s)?
(circle) yes
no
If you answered yes on question number 8, which breast(s) (circle) Left Right
Both
Also, indicate what type of Breast surgery you had and what year you had the surgery:
(Check the appropriate area)
____ Breast Implants
Year ____
____ Biopsy
Year ____
____ Lumpectomy
Year ____
____ Mastectomy
Year ____
____ Reduction
Year _____
Are you having any New or Current Problems with your breast(s) today? (circle) yes no
If you answered yes, please describe:
11.
_____________________________________________________________
_____________________________________________________________
PLEASE RETURN THIS SHEET TO THE FRONT DESK AND YOU WILL BE CALLED BY THE TECHNOLOGIST SHORTLY.
___________________________________________________________________________
O LUMP X BIOPSY SCAR □ PAIN
TECHNOLOGIST'S NOTES: __________________________________________________________

MOLE
____________________________________________________________________________________________________________________________
TECHNOLOGIST: _______________________________________