BREAST MRI QUESTIONNAIRE
Name:___________________________________________________ Other Cancer History:
Age: _____________ Height: _____________ Weight: ____________ Has a family member been tested for breast cancer gene?
YES ______ NO ______
Reason for MRI ____________________________________________
If yes, were they: POSITIVE ______ NEGATIVE ______
Previous Breast MRI? YES ______ NO ______
Have you been tested for the breast cancer gene?
If yes, when? _________________ Where? ______________________ YES ______ NO ______
How many breast biopsies have you had before? _________________ If yes, were you: POSITIVE ______ NEGATIVE ______
Breast Cancer History or Atypical Cell History:
If cancer, where was the biopsy performed? _____________________
_________________________________________________________
Date of diagnosis: __________________________________________
Which breast? (circle one) Right / Left / Bilateral
Chemotherapy
Yes ______ No ______
date at first use
date at last use
_____________
_____________
Radiation Therapy
Yes ______ No ______
_____________
_____________
Hormone Therapy:
Tamoxifen/Arimidex
Yes ______ No ______
_____________
_____________
Family History of Breast Cancer: (please provide age if known)
Mother _______
Sister _______
Father _______
Brother _______
Daughter _______ Son _______
Family History of Ovarian Cancer in:
Mother _______
Sister _______
Daughter _______
Right Breast
Right Breast:
_____________________________________________
_____________________________________________
Implant: ______________________________________
ISJ-436 (4/09)
Do you have Jewish heritage? YES ______ NO ______
High-risk lesion/Atypia: _________ Date ______________________
Ovarian Cancer: _____________ Date _____________________
Endometrial cancer: ____________ Date ______________________
Other (specify type): ______________________________________
Gynecological History:
Date of last menstrual period: _______________________________
First menstrual period at age: _______________________________
Number of births: _____________
First full-term pregnancy at age: _____________
Menopause at age: _____________
Left/Right ovary removed at age: _____________
Hysterectomy at age: _____________
Do you have implants? YES ______ NO ______
If yes, what type? ________________________________________
Have you taken Hormone Replacement Therapy?
YES ______ NO ______
Please tape a Vitamin E Capsule over any
palpable areas and previous scars.
Left Breast
Left Breast:
_____________________________________________
_____________________________________________
Implant: ______________________________________