Breast Evaluation
Last Name _________________________First Name______________ Date__________
History: the reason for breast MRI____________________________________
Do you still menstruate? __No __ Yes if so, what was the start date of your last period? ___________
Are you taking hormone replacement therapy? ___Yes ___No
Have you been diagnosed with Breast cancer? ___Yes
___No ___ Right ___Left
Date__________
Do you have BRCA gene? __Yes __No
Do you have family history of Breast cancer? ___Yes ___No
who? _______________Age________
Ovarian Cancer? _____ Who? _____________________
When was your last mammogram ______________ What was the result_______________________
Clinical Concerns: check all that apply
Do you or doctor feel a lump? __Yes __No __Right __Left
___ Breast pain ___Right __ Left
___ Nipple discharge __ Right __ Left
____ Recent breast injury __ Right __ Left
___ Breast skin changes __ Right __ Left
Abnormal mammogram/sonogram __ Right __ Left
Prior Breast Procedures: check all that apply
__ Fine Needle or Cyst Aspiration __ Right __ Left
__ Benign __ Malignant
Year_____
__ Needle or Core Biopsy __ Right __ Left
__ Benign __ Malignant
Year_____
__ Surgical lumpectomy or biopsy/excision __ Right __ Left
__ Mastectomy
If you had reconstruction, what type?
__ Breast Plastic Surgery
__ Benign __ Malignant
Year_____
_____ Flap reconstruction _____Implant
If so, what type? ___ Lift ___ Reduction ___ Implants (silicone or saline)
__If you have implants, what type, how long? ________________
__ Are your implants ______under the muscle ______over the muscle
Other Treatments: check all that apply
__ Radiation treatment to breast or chest
__ Chemotherapy __Yes ___No
___Yes ___No
Last Treatment Date ___________
Last Treatment Date _____________
TECHNOLOGIST WORK SHEET
REASON FOR BREAST MRI EXAM
__ Presurgical evaluation (recently diagnosed breast cancer)
__ High risk screening __ personal history of treated breast cancer
__ Family history of breast cancer
__ History of high risk lesion (ADH, ALH, LCIS)
__ Genetic predisposition (BRCA+)
__ Clinical concern (lump, breast pain, nipple discharge, skin changes)
__ Problem solving (mammographic or sonographic abnormality)
__ Response to chemotherapy
__ Short term follow up to prior MRI/MRI bx.
__ Rule out implant rupture