Virginia Chiantella MD, FACS
Specializing in Surgery of the Breast
_____________________________________________________________________
19415 Deerfield Ave Suite 213 Lansdowne, VA 20176
1800 Town Center Drive Suite 418, Reston VA 20190
(P) 703-724-9474
(F) 571-346-1921
Medical History Form: Please fill out completely and print clearly
Date:________________
First Name:__________________________ MI_____ Last Name:______________________
Birthdate:___________________
Age:_____
Who referred you to the practice?________________________________________________
Who is your primary care physician?______________________________________________
OB/GYN______________________________________________________
Pharmacy: (Name,City,Phone)_____________________________________________________
______________________________________________________________________________
WHAT IS THE REASON FOR TODAY’S VISIT? (Please check all that apply)
____I went for a routine visit, and my doctor felt a lump in ____my right ____my left ____both breast(s) and
recommended follow-up.
____I found a lump in ____my right ____my left ____both breast(s).
When did you first notice this? __________________________________________________
____I went for routine exam, my breast exam was fine, and I was sent for mammogram which came back abnormal.
____My mammogram shows a change when compared to my last mammogram.
____I have pain in ____my right ____my left ____both breast(s).
Please describe: ____constant ____cycles ____same spot ____location varies
When did you first notice this? ___________________________________________
____I have nipple discharge from _____my right _____my left _____both breast(s)
Color: ____________________________________________________________
When does this occur? ___spontaneously ___only when pressure is applied
____ daily ___intermittently
When did you first notice the discharge? _________________________________________________
____Other: (Please Specify) ____________________________________________________
I examine my breasts ____monthly ____intermittently ____rarely ____never
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Full Name:
Date of Birth:
Medications: (List all current medications)
Medication
Dose
Directions
Reason for Taking
List all NON PRESCRIPTION drugs, herbs, or supplements currently used:
Medication
Dose
Directions
Reason for Taking
Are you taking daily aspirin therapy?
Date:
Prescribed by
Prescribed by
____No ____Yes
ALLERGIES/INTOLERANCE
Are you allergic to, or sensitive to, LATEX or latex-containing items? ______No ______Yes
If yes, please describe reaction: ____________________________________________________
Has your skin reacted badly to adhesives, tapes, band-aids, or sutures? ______No ______Yes
Allergies: ( Medication and Reaction)
Medication
Reaction
Allergies: (List food and environmental)
2
Full Name:
Date of Birth:
Date:
Past Medical History (Please check any past condition and add any other significant condition not listed under Other)
Attention Deficit
Disorder
Gl Eczema
Insomnia
Anemia
Emphysema
Lupus
Asthma
Esophageal Reflux
Lyme Disease
Fatigue
Melanoma
Alcohol or Substance
Disorder
Lung Disease/COPD
Back Problems
Cancer
Concussion
Gastrointestinal
Disorder
Glaucoma
Non-migraine
Headache
HIV
Diabetes Mellitus
Dizziness/Vertigo
Depression
Heart disease
High Blood
Pressure
Arthritis
Easy Bleeding
Anxiety
Other
Migraine Headache
Osteoporosis/
osteopenia
Pneumonia
Rheumatoid
Arthritis
Seizure Disorder
Sleep Apnea/Use
CPAP
Stroke /TIA
Thyroid Disorder
SURGICAL HISTORY
Have you ever had: (Please check all that apply)
____A breast cyst aspirated (fluid removed from the breast with a needle) ____right ____left
____A breast core biopsy (needle inserted, not surgery) ____right _____left
____A breast biopsy (surgical) (a piece of tissue or lump removed) ____right ____left
Where was it done? ____________________________________________________________
When was it done? ____________________________________________________________
Results? ____________________________________________________________________
Do you have breast implants?
____No ____ Yes
Please list any prior surgery:
Date
1.
2.
3.
4.
5.
Date
6.
7.
8.
9.
10.
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Full Name:
Date of Birth:
Date:
FAMILY HISTORY
____There is no one in my family that I know of with a history of cancer.
Has any family member been tested for the “breast cancer gene” (BRCA 1 or 2)?
_______No _______Yes _______Don’t know
My family history is positive for: (Please list relationship to you, and their approximate age at diagnosis)
(Include father’s side)
(Mark with an X)
Cancer
Relative
Indicate
maternal/paternal
Maternal
Paternal Age at
Diagnosis
Deceased
from this
cancer? If
yes, at what
age?
Age
Now
Breast Cancer
Ovarian
Cancer
Uterine Cancer
Colon Cancer
Pancreatic
Cancer
Prostate
Cancer
Thyroid Cancer
Melanoma
Other
SOCIAL HISTORY/HABITS
Do you currently smoke?
Are you a former smoker?
Do you drink alcohol?
Drinks per typical day when drinking
How often, per single occasion, 6
drinks or more?
No
Yes
How many cigarettes per day do you smoke?
For how long? (Years)
[ ] No [ ] Yes If yes, how many cigarettes per day?________
If yes, for how long?________
When did you quit?________
No
Yes: [] monthly or less []2-4 times/month
[]2-3 times/week [] 4 or more times/week
[] 1-2 []3-4 [] 5-6 []7-9 [] 10 or more
[] never [] less than monthly [] monthly []weekly []daily/almost daily
Some races/ethnic groups carry a higher incidence of breast cancer-related genes, which is why we
ask you to identify your family origin: ____Eastern European ____Northern European _____Asian
_____Western European _____Native American ____Middle Eastern _____African American
_____Pacific Islander _____Caribbean _____Central/South American _____Hispanic
_____Non-Hispanic _____ Ashkenazi (Eastern European Jewish)
_____Caucasian
____Other:___________________________________
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Full Name:
Date of Birth:
Date:
GYN HISTORY:
Age periods started: _________________________ Age at menopause, if applicable: __________________________
Have you had a hysterectomy?
____No
____Yes, including removal of both ovaries
____Yes, but one ovary, or a piece of ovary, was not removed.
____Yes, but neither ovary was removed.
____Yes, but I don’t know if my ovaries were removed.
Age at hysterectomy________
Reason for hysterectomy: (Please check all that apply)
____Abnormal bleeding
____Endometriosis
____Fibroids
____Pelvic infections
____Uterine cancer
____Bladder problems
____Pre-Cancer of Cervix
____Cancer of Cervix
____Pelvic Pain or Adhesions
____Other Reason: ___________________________________________________________
Have you ever used estrogen replacement? (This does NOT includes vaginally inserted medicines or oral
contraceptives) ____No ____Yes
If yes, for how long? ______________
Are you using it currently? ______No ______Yes
If you no longer use it, when did you stop using?___________________
If using, please list your current hormone medication(s) and dose(s):___________________________
Has the type or dose been changed recently? ____No ____Yes
Have you ever used oral contraceptives? _____No
______Yes
If yes, for how long?_________________ Are you using it currently? ______No ______Yes
OB HISTORY
If you are pregnant, how many weeks? ____________
Due date ____________________________
Number of pregnancies: _______ Number of live births:_______ Age at first live birth:_______
Have you ever breast fed? ____No ____Yes If yes, total number of months (all children combined): _______
Have you ever taken fertility drugs? ____No ____Yes
Please list your: Height ___________ft __________inches Weight __________lbs Bra Size _____
YOU’RE ALMOST DONE!!
For Office Use Only:
BP:____________________
HR:___________________
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Full Name:
Date of Birth:
Date:
REVIEW OF SYSTEMS (Please only check symptoms that you currently experience)
Constitutional Symptoms
_____hot flashes ____insomnia
____night sweats _____weight gain _____weight loss
Allergy/Immunology
____History of MRSA
Eyes
____Immune deficiency
_____HIV positive
____migratory pain
____Environmental allergies
____Current allergy shots
___Blindness ____Cataracts ____Glaucoma ____Retina Problem
ENT ____Dizziness ____Change in voice
____Tooth problems ___Bleeding gums
____Difficulty swallowing ____Ear problems _____Nosebleed ____Sore throat
Endocrine
____Hypoglycemia ____Goiter/thyroid surgery ____Low thyroid
____Diabetes
Respiratory
____Cough
____Emphysema/COPD
____Tuberculosis
Gastrointestinal
____Diverticulosis
____Blood in stool
_____Phlebitis
____Hyperthyroid
_____Chest pain
____Hiatal hernia ____Ulcers ____Acid reflux ____Liver disease ____Cirrhosis
____Polyps
____Irritable bowel ____Gluten intolerance/celiac disease
____Hepatitis ____Nausea
Hematology ____Blood clots/clotting disorder _____Sickle cell disease/trait
_____Bleeding problems
Gyn/Urinary
____Sinus problems
____ Sleep apnea ____Use CPAP/BIPAP ____Asthma
Cardiovascular
____Heart disease ____Ankle swelling
____High blood pressure ____ Irregular heartbeat
____Anemia
____Postmenopausal ____Irregular menses _____Urinary leakage _____Kidney problems
Muscular/Skeletal ____Osteoporosis ____Neck Pain
____Artificial joints ____Disc problems ____Arthritis
Skin
____ fever
____Back pain
____Fibromyalgia
____Psoriasis ____Eczema ____Melanoma
Nervous System
Psychiatric
____Migraine
___Mini-stroke/TIA ____Seizures _____Stroke
____Bipolar ____Anxiety
Any complaints not listed above?
____Depression ____Drug/Alcohol problem
______________________________________________________
DONE! Thank you!
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