For Office Use Only: ID #: __________________
MRN: __________________
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Chart information - BREAST ONCOLOGY/SURGERY
Columbia University Medical Center at New York-Presbyterian Hospital
Do you have the following? (select one):
Breast cancer or ductal carcinoma in situ (DCIS)
2 Benign breast disease or high risk for breast cancer
3 Don’t know
1
DEMOGRAPHICS:
Patient E-Mail:
Preferred Language:
1
2
Place of Birth:
English
Spanish
________________________________________________________________
City
State
Country
1. Age (Years): ____________
2. Height:
____________
3. Weight:
____________
4. Race:
inches
pounds
cm
kg
White/Caucasian
2 Black/African American
Asian
4 Other_______________________________
1
5. Do you consider yourself:
3
1
Non-Hispanic
3
Other__________________________
2
5a. If Hispanic or Latina, which best describes your ethnicity?:
Hispanic or Latina
Dominican
Puerto Rican
3 Cuban
4
2
5
6. Country of Family Origins: Mother ________________________________
Unknown
Mexican
Ecuadorian
6 Other _________________________
1
Father___________________________________________
Maternal Grandmother ___________________ Paternal Grandmother ____________________________
Maternal Grandfather ____________________ Paternal Grandfather ____________________________
7. Religion:
Buddhist
Catholic
3 Christian
4 Hindu
5 Islam
6
2
7
7a. If Jewish
8. Marital Status:
Jewish
Muslim
8 Sikh
9 Other ______________________
1
1
Ashkenazi
Single
Married
3 Divorced/ Separated
2
Sephardi
1
4
2
5
9. Education (highest level completed):
1
2
10. Employment:
Full-time
Part-time
3 Self-Employed
4 Unemployed
5 Student
3
Other __________________
Widowed
Domestic partnership
Grade School
High School
3
4
College
Graduate School
Homemaker
Disabled
8 Retired
9 Other ________________________
1
6
2
7
11. Current/Former Occupation: ____________________________________________
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Chart Information: Breast Oncology and Surgery
For Office Use Only: ID #: __________________
MRN: __________________
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12. Annual Household Income:
0-$15,000
$15,001 to $30,000
3 $30,001 to $60,000
4 $60,001 to $100,000
5 $100,000+
6 Refused
1
2
HORMONAL AND REPRODUCTIVE FACTORS
13. Age at start of menstrual periods (years): ________________
14. Have you ever been pregnant?
1
No
2
Unknown
Yes
14a. If yes, number of times pregnant: ________________
Not applicable
14b. If yes, number of live births: _____________________
Not applicable
14c. Did you ever take fertility medications to become pregnant?
15. Age at first live birth (years): ___________________
16. Did you breast feed any of your children?
No
2
Yes
Not applicable
1
16a. If yes, how many months did you breast feed?
1
No
2
Yes
3
Not applicable
2
Yes
less than 6 months
6 month-1 year
3 1-2 years
4 more than 2 years
1
2
17. Have you ever used hormonal methods of birth control?
17a. If Yes, for how long in total have you used it?
1
No
less than 6 months
6 month-2 year
3 2-5 years
4 more than 5 years
1
2
18. When was your last menstrual period?
19. Have your menstrual periods stopped permanently?
19a. If yes, stopped within the last 6 months
Unknown
__________/____________
MM
YYYY
1
No
2
Yes
3
Unknown
stopped more than 6 months ago
1
19b. If yes, was your menopause natural or a result of surgery?
19c. Did you have a hysterectomy?
1
No
2
Yes
19d. Were both your ovaries removed?
1
No
2
One
1
Natural
2
Surgical
2
3
Other___________
Reason:________________________
3
Both
Reason:________________________
19e. At what age was your last menstrual period:__________________
20. Have you ever taken hormone replacement therapy?
1
No
20a. If yes, type of treatment: ___________________________
20c. If yes, duration:
2
Yes
20b. Years since last use: _________________
less than 6 months
2 6-12 months
1-5 years
4 >5 years
1
21. Are you taking or have you ever taken tamoxifen or raloxifene (Evista)?
21a. If yes, reason for treatment: ___________________________
21b. If yes, duration:
1 less than 3 months
2 3-6months
3
1
No
2
3
6-12 months
>1 year
4
Yes
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Chart Information: Breast Oncology and Surgery
For Office Use Only: ID #: __________________
MRN: __________________
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MEDICAL HISTORY
22. Do you have any chronic illnesses?
1
No
2
Yes
22a. If yes, check all that apply:
Arthritis/Rheumatism
Asthma
3 Blood Clots
4 Cancer
5 Colitis
6 Diabetes
7 Heart Disease/ Heart Attack
8 High Blood Pressure
9 High Cholesterol
HIV/AIDS
Kidney Disease
12 Liver Disease
13 Lung Disease
14 Peripheral Vascular Disease
15 Stroke
16 Thyroid Disease
17 Ulcers
18 Other: _____________________________________
1
10
2
11
23. Do you have a history of benign breast disease?
1
No
2
Yes
3
Unknown
23a. If yes, how many biopsies:______
23b. If yes, please specify:
Atypical ductal hyperplasia (ADH):
Atypical lobular hyperplasia (ALH):
Lobular Carcinoma In Situ (LCIS)
or Lobular Neoplasia:
Fibroadenoma:
Breast Cyst(s):
History of nipple discharge:
Other:_______________________
Yes
Yes
No Dates _____________________
No Dates _____________________
Left
Left
Right
Right
Both
Both
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Left
Left
Left
Left
Left
Right
Right
Right
Right
Right
Both
Both
Both
Both
Both
Dates
Dates
Dates
Dates
Dates
_____________________
_____________________
_____________________
_____________________
_____________________
24. Have you ever had cancer on a breast biopsy?
1
24a. If yes, please specify:
Year
No
2
Yes
3
Unknown
Result
Right
Left __________________
1
Invasive ductal cancer
2 Invasive lobular cancer
3
Right
Left __________________
1
Invasive ductal cancer
Invasive lobular cancer
3
2
25. Have you ever had a mammogram?
Ductal carcinoma in situ (DCIS)
4 Unknown
4
1
No
2
Yes
Ductal carcinoma in situ (DCIS)
Unknown
3
Unknown
25a. If yes, how old were you when you had your first mammogram (years)? ______________________
25b. If yes, how often do you have mammograms?
1
2
Yearly
Every 1-2 years
3
4
Unknown
Every 2-3 years
Other ______________________
25c. If yes, what was the date of your last mammogram? ______________________________________
Unknown
26. Have you ever had a breast ultrasound?
1
No
2
Yes
3
Unknown
27. Have you ever had a breast MRI?
1
No
2
Yes
3
Unknown
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Chart Information: Breast Oncology and Surgery
For Office Use Only: ID #: __________________
MRN: __________________
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ENVIRONMENTAL EXPOSURES
28. Did you ever undergo radiation treatment to the neck or chest area?
1
No
2
Yes
3
Unknown
(for example: treatment for Hodgkin’s lymphoma)
29. Are you currently a smoker?
1
No
2
Yes
30. Did you ever smoke at least 1 cigarette per day for one month or longer?
1
No
2
Yes
30a. If yes, how old were you when you first started (years)? ___________
30b. If Yes, how many years have you smoked?
30c. How many cigaretttes per day?
1
less than 1 year
1-5 years
3 6-10 years
4
2
5
1
More than 2 packs
1-2 packs
3 ½-1 pack
4
2
5
½ pack or less
once in a while
1
No
30d. At what age did you stop smoking cigarettes: ___________
more than 10 years
once in a while
Not applicable
31. As an adult or child did any member of your household smoke?
2
Yes
LIFESTYLE
32. How often did you have a drink containing alcohol in the past year?
Never
Monthly or less
2 2-4 times per month
32a. If applicable, what type?
0
3
1
4
1
Beer
2
2-3 times per week
≥4 times per week
Red or White Wine
3
Hard liquor/ mixed drink
32b. If applicable, how many drinks did you have on a typical day when you were drinking the past year?
0 One or less
2 Three drinks
1 Two drinks
3 Four or more drinks
33. How would you characterize your diet? (select one)
Red meat, potato, vegetables, butter and bread on a regular basis
Attempt to lower fat intake
3 Strict low-fat diet
4 Low Carb diet
5 Modified vegetarian (including fish)
6 Strict vegetarian
7 Vegan
1
2
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Chart Information: Breast Oncology and Surgery
For Office Use Only: ID #: __________________
MRN: __________________
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34. Think about your eating habits in the past year or so. About how often did you eat each of the following
foods? Remember breakfast, lunch, dinner, snacks and eating out. (Check one box per line.)
Less
than
1/WEEK
Fruits, Vegetables, and Grains
Fruit juice, like orange, apple, grape, fresh,
frozen or canned. (Not sodas or other
drinks)
How often do you eat any fruit, fresh or
canned (not counting juice?)
Vegetable juice, like tomato juice, V-8,
carrot
Once a
WEEK
2-3
times
a
WEEK
4-6
times
a
WEEK
Once
a DAY
2+ a
DAY
Green salad
Potatoes, plantains, sweet potatoes, yams,
yucca or cassava, including baked, mashed
or french fried
Vegetable soup, or stew with vegetables
Any other vegetables, including string
beans, peas, corn, broccoli, chayote,
jicama, avocados or any other kind
Fiber cereals like Raisin Bran, Shredded
Wheat or Fruit-n-Fiber
Beans such as baked beans, red beans,
black beans, pigeon beans, pinto beans,
kidney beans, or lentils (not green beans)
Dark bread such as whole wheat or rye
35. Do you take vitamins?
1
35a. If yes, what type (check all that apply)?
No
2
Yes
Vitamin A
Beta-carotene/multiple carotenids
3 Vitamin C
4 Vitamin D
Vitamin E
Calcium
7 Multivitamin
8 Other: _________________________
1
5
2
6
36. Do you take any other herbal or nutritional supplements?
1
No
2
Yes
36a. If yes, check all that apply:
Gingko Biloba
Echinacea
3 St. John's Wort
4 Glucosamine Chondroitin
5 Black Cohosh
Ginseng
Green Tea
8 Omega-3 fish oils
9 CoQ10
10 Other: ________________________________
1
6
2
7
PHYSICAL ACTIVITY
37. During a typical week, how much times do you engage in vigorous physical activity that causes your heart to
beat rapidly and/or to produce a sweat?
1 None
5 2-3
2 less
6 3-4
than 30 minutes
3 30-60 minutes
4 1-2 hours
hours
hours
7 4+ hours
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Chart Information: Breast Oncology and Surgery
For Office Use Only: ID #: __________________
MRN: __________________
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FAMILY HISTORY
38. Have you ever been diagnosed with any other cancer?
1
No
2
Yes
1
No
2
Yes
3
Don’t know
2
Yes
3
Don’t know
2
Yes
If Yes, what type?
39. Have you ever had genetic testing?
39a. If yes, Result: Positive 1 / Negative
2 (for a genetic mutation)
39b. if Positive: what type of mutation (i.e., BRCA1, BRCA2, etc.):_____________
40. Have any of your relatives ever had genetic testing?
1
No
40a. If yes, Result: Positive 1 / Negative
2 (for a genetic mutation)
40b. if Positive: what type of mutation (i.e., BRCA1, BRCA2, etc.):_____________
41. Do you have any relatives with breast cancer?
1
No
If yes, please detail your family history of breast cancer below. Include relatives such as mother, father, sister, brother, daughter, son,
grandmother, grandfather, aunt, uncle, and cousin.
Relative
Maternal/Paternal
Age at
Diagnosis
Alive (Y/N)
 Maternal  Paternal
 Y  N
 Maternal  Paternal
 Y  N
 Maternal  Paternal
 Y  N
 Maternal  Paternal
 Y  N
 Maternal  Paternal
 Y  N
 Maternal  Paternal
 Y  N
 Maternal  Paternal
 Y  N
 Maternal  Paternal
 Y  N
 Maternal  Paternal
 Y  N
Location
Unilateral
 Bilateral
Unilateral
 Bilateral
Unilateral
 Bilateral
Unilateral
 Bilateral
Unilateral
 Bilateral
Unilateral
 Bilateral
Unilateral
 Bilateral
Unilateral
 Bilateral
Unilateral
 Bilateral
42. Do you have any relatives with cancers other than breast cancer?
1
Menopausal Status
 Pre Post Menopausal
 Pre Post Menopausal
 Pre Post Menopausal
 Pre Post Menopausal
 Pre Post Menopausal
 Pre Post Menopausal
 Pre Post Menopausal
 Pre Post Menopausal
 Pre Post Menopausal
No
2
Yes
If yes, please detail your family history of cancer below. Include relatives such as mother, father, sister, brother, daughter, son,
grandmother, grandfather, aunt, uncle, and cousin.
Relative
Maternal/Paternal
Type of Cancer
Age at
Diagnosis
Alive
(Y/N)
Maternal Paternal
YN
Maternal Paternal
YN
Maternal Paternal
YN
Maternal Paternal
YN
Maternal Paternal
YN
Maternal Paternal
YN
Maternal Paternal
YN
Maternal Paternal
YN
Maternal Paternal
YN
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Chart Information: Breast Oncology and Surgery