Physiotherapy Breast Assessment Form ID verified Name ………………………………………........................... D.O.B. ……………………….......… Assessment date ………………................……....... Address …………………………………………………............. Phone ……..................…....... Referrer ……................ Doctor…………….……...… PRESENTING PROBLEM ............................................................................................................................................................................................................... .............................................................................................................................................................................................................. .............................................................................................................................................................................................................. Investigations/Management (& effectiveness).................................................................................................................................. ............................................................................................................................................................................................................ Consultation with GP, LC, CHN ........................................................................................................................................................... Fever or flu-like symptoms Yes No Onset/Duration ........................................................................................................... DELIVERY DETAILS and OBSTETRIC HISTORY Delivery Date …………................... Baby’s Birth Weight …….......…….…. Gestation …............…….………………………………………………... Complications …………………………………………………………………………………………………………………………………………………………………………….. G ___ P ____ Age of Children ……………….........………………………………………………………………………………………………………………………… METHOD & PATTERN OF FEEDING Breast only / Tube / Breast and expressing / Expressing only / Other ............................................................................................... Recent changes .................................................................................................................................................................................. Breast refusal/preference ............................................................ Baby gaining weight?................................................................... Milk flow same both breasts? .........................................................Correct Attachment?................................................................... Difficulty with attachment (VAS): Right ......../10 Left ....../10 Pain with attachment (VAS): Right ........./10 Left ....../10 Start of Feed Throughout Feed ............................................................................................................................................................................................................. HISTORY BREASTFEEDING Previously breastfed? Yes No Past Hx engorgement, blocked ducts, mastitis, nipple trauma?...………………....................................................................................... .............................................................................................................................................................................................................. Same area of breast? Yes No Management..................................................................................................................... .............................................................................................................................................................................................................. MEDICAL/SURGICAL Breast Surgery/Implants ...................................................................................................................................................................... Nipple piercing (current/previous) Thrush: Mother (current/pregnancy), Baby (circle as approp) Hep/HIV/STI/Herpes/CMV Anaemia General Health…………………………………………………………......................................................................................................................... MEDICATIONS ..…………………………………………………………………………………..............................……………...........................….........………… 1 FLUID INTAKE Volume ……………………. Type of fluid …………………………………………………..........................................................…..... OBJECTIVE ASSESSMENT Temperature (°C) ............................................................ Pulse rate (bpm).................................................... Colour of affected area Degree of tenderness Right Normal ---– Pink ---– Very Pink ---– Red ----- Dark Red Left Normal ---– Pink ---– Very Pink ---– Red ----- Dark Red Localised Generalised Right..................../10 Left ..................../10 RIGHT (VAS) LEFT ANALYSIS …………………………………………………………………………………………………………………………………..………………………………………………… .............................................................................................................................................................................. .............................................................................................................................................................................. MANAGEMENT PLAN C/I & PRECAUTIONS ………………………………………………………………………................................ ............................................................. ………………………………………………………………………................................ ............................................................. ………………………………………………………………………................................ ............................................................. ………………………………………………………………………................................ ............................................................. Informed Consent INITIAL TREATMENT .............................................................................................................................................................................. ................................................................................................................................................................................ ................................................................................................................................................................................ .............................................................................................................................................................................. ................................................................................................................................................................................ ................................................................................................................................................................................ .............................................................................................................................................................................. ................................................................................................................................................................................ ................................................................................................................................................................................ Natalie Bull/Patricia Gaunt/Alison Lutz © Copyright 2010 2
