The Mount Sinai Hospital
One Gustave L. Levy Place
New York, New York 10029
BREAST SURGICAL ONCOLOGY: NEW VISIT FORMS
Elisa R. Port, MD, FACS
Hank Schmidt, MD, PhD, FACS
Christina Weltz, MD
Ph) 212-241-3806 Fax) 212-202-4590
Ph) 212-241-5928 Fax) 212-202-4633
Ph) 212-241-3956 Fax) 212-241-0703
In order to ensure the highest quality of care, in a timely fashion, it is important that we have all of your
medical information at the time of your initial visit. For your initial visit, we ask you to bring any
documentation pertaining to tests/procedures you have had done. We also ask that you fax all reports and
send all radiology images to our office prior to the appointment. Providing all the medical information prior to
your visit will make your visit more comprehensive. Listed below are tests/procedures you may have had.
RADIOLOGY FILMS AND REPORTS: The physicians will require all films and reports prior to your
appointment. Please provide any tests you have had i.e.: mammogram, sonogram, MRI. Please ensure that
all films, for both sides of your breast, be sent even if only one side is affected. Your surgeon needs both the
films and corresponding reports to provide a complete evaluation to provide an appropriate assessment
and plan. Official radiology reports can usually be provided to you by the ordering physician’s office. We will
have to reschedule visits when films and reports are not available for the doctor’s review.
ADDRESSES: Please bring complete addresses, phone numbers and fax numbers for any of your doctors
who you would like reports sent.
PATHOLOGY REPORTS: If you have had a biopsy at another institution, please have that report sent our
office.
PATHOLOGY SLIDES: If there is going to potentially be treatment and your pathology slides are at another
institution, they will want them to be reviewed by our pathologists here at Mount Sinai. Please obtain them
from the hospital where your biopsy was performed. Call the Pathology Department of that hospital to
arrange to personally pick them up or if it is more convenient, you can request that the hospital send your
slides to our office.
OPERATIVE REPORTS: If you have had breast surgery recently with another surgeon please call that office
and request a copy of the operative report to be sent to us.
INSURANCE REFERRALS: Please check with your insurance carrier to find out if your plan requires a
referral from your primary care physician. This information can be found on your insurance card. If a referral
is not present at the time of the appointment, it will be the patient’s responsibility for services rendered and/or
you may be rescheduled.
Having this information available for review at the time of your visit will allow our physicians to provide you
with the highest quality of care. If there are studies or results you cannot provide for the visit, we recommend
you reschedule your appointment to a time when you will be able to provide everything.
Should you have any further questions regarding what to bring please call our offices at the number listed
above.
MR-1775
Page 1 of 7 Pages
The Mount Sinai Hospital
One Gustave L. Levy Place
New York, New York 10029
BREAST SURGICAL ONCOLOGY: NEW VISIT FORMS
Name:____________________________________________________________________
NOTE TO PERSON
DESIGNING FORM
Date of Birth:_____________________
Age:____________________
All text, lines, etc. must be within the established margins as noted.
Preferred phone number:____________________________________
(The outside line should not be included on the final form)
Primary Insurance Plan:______________________________________
With whom is your appointment?: _____________________________________________
FONT:
No smaller than 8 points nor larger than 14 points.
Appointment Date:
_____________________________________
Document is typed in standard Arial.
REASON FOR VISIT
SIZE:
- - Only forms measuring 8.5" x 11.0" are sized for inclusion within the medical chart.
Referring Physician: ______________________________________________________
- - For Landscape Design ensure margin with hole punch = .75"
Reason for referral: _______________________________________________________
PAPER:
White 20# paper.
Was your referral due to a finding on a breast exam by a physician?
YES NO
Which breast?INK:Right
Black isLeft
required.
Both
Did you find something
self exam?
YES NO
FORM # &on
APPROVED/REVISION
DATE:
If so, when did you find it? ________________________________________
Must appear on all pages of the form in the lower left hand corner.
Do you have symptoms?
YES NO
Pain
YES NO
GENERAL:
- - Avoid shading.
Nipple Discharge
YES NO
- - Live data should not be used
Lump
YES
NO
- - If it is impossible to eliminate live data from an IT generated form, the name and MRN
Skin Changes (rash or dimpling)
YES NO
MUST be blacked out.
Other______________________________
GYNECOLOGICAL
HISTORY
MULTIPLE
PAGES:
- - Indicate Page __ of ___ Pages on lower right hand corner of all pages.
What age did you first start menstruating? __________
- - Patient name and medical record number should be included on each
When was your last menstrual subsequent
period? _____________
page.
Have you ever been pregnant?
Are you currently pregnant?
Due date: ______________________
# of pregnancies: ____
# of children: _____
Did you breastfeed?
If yes, how long?________________
YES
YES
NO
NO
Age of first delivery? _______
YES
NO
YES NO
Have you ever taken hormone replacement pills?
If yes, When? _____________________
How long? ______________________
Have you ever taken oral contraceptives?
YES
NO
If yes, when? _______________
Have you ever been treated for infertility?
YES
NO
If yes, when? _______________
Page 2 of 7 Pages
The Mount Sinai Hospital
One Gustave L. Levy Place
New York, New York 10029
BREAST SURGICAL ONCOLOGY: NEW VISIT FORMS
NOTE TO PERSON DESIGNING FORM
All text, lines, etc. must be within the established margins as noted.
(The outside line should not be included on the final form)
BREAST HISTORY
Have you ever had breast surgery in the past?
FONT:
YES
NO If so, when? _______________
No smaller than 8 points nor larger than 14 points.
What was the diagnosis?Document
____________________________________
is typed in standard Arial.
Type of surgery? _________________________________
SIZE:
- - Only forms measuring 8.5" x 11.0" are sized for inclusion within the medical chart.
- - For Landscape Design ensure margin with hole punch = .75"
Have you ever had a needle biopsy in the past?
YES
NO If so, when? _______________
PAPER:
20# paper.
What was the
diagnosis?White
_____________________________________
MEDICAL HISTORY
INK:
Black is required.
Height: _________________
Weight: _________________________
FORM # & APPROVED/REVISION DATE:
corner.
□ High Blood Pressure Must appear on all pages of the form in the lower left hand
YES
NO
□ Diabetes
YES NO
GENERAL: - - Avoid shading.
□ Cardiac Disease
YES NO
- - Live data should not be used
□ Asthma/COPD
YES NO
□ Blood clot
YES form,
NO the name and MRN
- - If it is impossible to eliminate live data from an IT generated
□ Other ___________________________________________________
MUST be blacked out.
Do you currently have pain, unrelated to your reason for visit?
YES NO
MULTIPLE PAGES:
If yes, are you seeing an MD/NP/PA for this pain?
YES NO
- - Indicate Page __ of ___ Pages on lower right hand corner of all pages.
If yes, on a scale of 1-10, how would you rate your pain?______________________________
- - Patient name and medical record number should be included on each
page.
Have you fallen in the last subsequent
year?
YES
NO
Do you require walking aids (cane, walker, wheelchair)?
YES
NO
Do you have episodes of dizziness or fainting?
YES
NO
PAST SURGICAL HISTORY: Please list below all your past operations with reason and date.
OPERATION
REASON
DATE
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Page 3 of 7 Pages
The Mount Sinai Hospital
One Gustave L. Levy Place
New York, New York 10029
BREAST SURGICAL ONCOLOGY: NEW VISIT FORMS
NOTE TO PERSON DESIGNING FORM
All text, lines, etc. must be within the established margins as noted.
(The outside line should not be included on the final form)
MEDICATIONS/ALLERGIES:
Left
Margin
Right Margin
.75"
.4"
Do you take Coumadin (Warfarin), Plavix, Aspirin, Vitamin E or any other blood thinning medications?
YES
NO
FONT:
No smaller than 8 points nor larger than 14 points.
Are you allergic
to any medications?
Document is typed in standard Arial.
If so, please list medication and reaction:
YES
NO
SIZE:
- - Only forms measuring 8.5" x 11.0" are sized for inclusion within the medical chart.
_____________________________________________________
- - For Landscape Design ensure margin with hole punch = .75"
_____________________________________________________
PAPER:
White 20# paper.
_____________________________________________________
INK:
SOCIAL HISTORY
Black is required.
FORM # & APPROVED/REVISION DATE:
Occupation: ______________________________________
Must appear on all pages of the form in the lower left hand corner.
Do you currently smoke?
YES NO If Yes, # of packs/year________________
GENERAL: - - Avoid shading.
Have you smoked in the past?
YES NO When did you quit? ___________________
- - Live data should not be used
eliminate
live data
an IT generated form, the name and MRN
Do you consume alcohol? - - If it is impossible to YES
NO
Howfrom
often?__________________________
MUST be blacked out.
Do you take any recreational drugs?
YES NO How often?________What kind?_________
MULTIPLE PAGES:
FAMILY HISTORY OF CANCER
- - Indicate Page __ of ___ Pages on lower right hand corner of all pages.
- - Patient name and medical record number should be included on each
□ None
subsequent page.
□ Breast Cancer
Relationship _______________________ Age at diagnosis _______
Relationship _______________________ Age at diagnosis _______
□ Ovarian Cancer
Relationship _______________________ Age at diagnosis________
Relationship _______________________ Age at diagnosis________
□ Other ________________
Relationship _______________________ Age at diagnosis ________
Relationship _______________________ Age at diagnosis_________
Have you or anyone in your family been tested for BRCA 1 & 2 breast cancer gene?
YES
NO
If so who: _____________________________________________________________________
_______________________________________________________________________________________
Page 4 of 7 Pages
The Mount Sinai Hospital
One Gustave L. Levy Place
New York, New York 10029
BREAST SURGICAL ONCOLOGY: NEW VISIT FORMS
NOTE TO PERSON DESIGNING FORM
All text, lines, etc. must be within the established margins as noted.
(The outside line should not be included on the final form)
REVIEW OF SYSTEMS: Please check “Yes” or “No” as they relate to your health.
FONT:
No smaller than 8 points nor larger than
14 points.
Constitutional
Gastrointestinal
Document
□ Fatigue
YESis typed
NO in standard Arial. □ Change in Stool
YES NO
□ Fever
YES NO
□ Abdominal pain
YES NO
□ Chills
NO
Constipation
YES chart.
NO
SIZE:
- - OnlyYES
forms measuring
8.5" x 11.0"□are
sized for inclusion within the medical
□ Weight loss
NODesign ensure margin
□ Other
_____________
- - For YES
Landscape
with hole
punch = .75"
□ Other _____________
PAPER:
White 20# paper.
Cardiac
□ Chest pain
YES NO
Black is
required.
□ PalpitationsINK:
YES
NO
□ Dizziness
YES NO
FORM # & APPROVED/REVISION DATE:
□ Other _____________
Genitourinary
□ Painful urination
□ Bloody urination
□ Other _____________
YES
YES
NO
NO
Must appear on all pages of the form in the lower left hand corner.
Respiratory
Eyes, Ears, Nose and Throat
□ Shortness GENERAL:
of Breath - - Avoid
YES
NO
□ Change in Vision
YES NO
shading.
□ Coughing
YES NO
□ Pain Swallowing
YES NO
- - Live data should not be used
□ Wheezing
YES NO
□ Vertigo
YES NO
- - If it is impossible to eliminate live data from an IT generated form, the name and MRN
□ Other _____________
□ Nasal Stuffiness
YES NO
MUST be blacked out.
□ Other _____________
Neurologic MULTIPLE PAGES:
Musculoskeletal
□ Headaches
YESPage
NO
Jointright
pain
YES
- - Indicate
__ of ___ Pages on□lower
hand corner of all pages.
□ Dizziness
YES
NO
□
Muscle
spasm
YES
- - Patient name and medical record number should be included on each
□ Numbness
YES NO
□ Swelling
YES
subsequent
page.
□ Memory Loss
YES NO
□ Other _____________
□ Other _____________
Vascular
□ Leg cramps
□ Tissue loss
□ DVT
□ Other _____________
YES
YES
YES
NO
NO
NO
Psychiatric
□ Anxiety
□ Change in sleep pattern
□ Depression
□ Other ____________
YES
YES
YES
NO
NO
NO
NO
NO
NO
Page 5 of 7 Pages
The Mount Sinai Hospital
One Gustave L. Levy Place
New York, New York 10029
BREAST SURGICAL ONCOLOGY: NEW VISIT FORMS
PHYSICIANS:
Please list the
physicians
would
like
reports
All text,
lines, etc. must beyou
within the
established
margins
as noted.sent to below.
NOTE TO PERSON DESIGNING FORM
(The outside line should not be included on the final form)
Name: _______________________________________________
Address: _____________________________________________
_____________________________________________________
FONT:
No smaller than 8 points nor larger than 14 points.
City, State,
Zip Code:
_______________________________
Document is typed in standard Arial.
Phone: ____________________________
SIZE:
- - Only forms measuring 8.5" x 11.0" are sized for inclusion within the medical chart.
Fax: _______________________________
- - For Landscape Design ensure margin with hole punch = .75"
PAPER:
White 20# paper.
Name: ________________________________________________
Black is required.
Address:INK:
______________________________________________
______________________________________________________
FORM # & APPROVED/REVISION DATE:
City, State,
Zip Code: _______________________________
Must appear on all pages of the form in the lower left hand corner.
Phone: ____________________________
GENERAL: - - Avoid shading.
Fax: _______________________________
- - Live data should not be used
- - If it is impossible to eliminate live data from an IT generated form, the name and MRN
PREFERRED PHARMACY:
Please list your preferred pharmacy contact information below.
MUST be blacked out.
MULTIPLE PAGES:
- - Indicate Page __ of ___ Pages on lower right hand corner of all pages.
Name: ________________________________________________
- - Patient name and medical record number should be included on each
Address: ______________________________________________
subsequent page.
______________________________________________________
City, State, Zip Code: _______________________________
Phone: ____________________________
Fax: _______________________________
PATIENT NAME (Print)_____________________________________
PATIENT SIGNATURE______________________________________DATE____________
Page 6 of 7 Pages
The Mount Sinai Hospital
One Gustave L. Levy Place
New York, New York 10029
BREAST SURGICAL ONCOLOGY: NEW VISIT FORMS
NOTE TO PERSON DESIGNING FORM
All text, lines, etc. must be within the established margins as noted.
(The outside line should not be included on the final form)
HOME MEDICATION LIST: Please list all prescription, over the counter and herbs/supplements.
NAME
Example: Aspirin
FONT:
1.
2.
ROUTE
Oral
DOSE
81 mg
FREQUENCY
Daily
___________
No smaller than 8 points nor larger than 14 points.
Document is typed in standard Arial.
SIZE:
- - Only forms measuring 8.5" x 11.0" are sized for inclusion within the medical chart.
- - For Landscape Design ensure margin with hole punch = .75"
3.
4.
5.
6.
PAPER:
White 20# paper.
INK:
Black is required.
FORM # & APPROVED/REVISION DATE:
Must appear on all pages of the form in the lower left hand corner.
GENERAL: - - Avoid shading.
- - Live data should not be used
7.
- - If it is impossible to eliminate live data from an IT generated form, the name and MRN
MUST be blacked out.
8.
MULTIPLE PAGES:
9.
10.
- - Indicate Page __ of ___ Pages on lower right hand corner of all pages.
- - Patient name and medical record number should be included on each
subsequent page.
MEDICATIONS/ALLERGIES:
Are you allergic to any medications?
YES
NO
If so, please list medication and reaction below:
_____________________________________________________
_____________________________________________________
PATIENT NAME (Print)_____________________________________
PATIENT SIGNATURE______________________________________DATE____________
CLINICIAN NAME (Print)____________________________________
CLINICIAN SIGNATURE__________________________REVIEWED DATE____________
Page 7 of 7 Pages