PATIENT HISTORY
NAME: _______________________________________________________ DATE: __________________________________
AGE: ___________ DOB: ___________________
What is your main breast complaint?
_____Pain
FEMALE: ______ MALE: ________
_____Lump-who found it? _____________ Side: Rt______Lt_______
_____Skin changes
_____ Nipple Change
_______Abnormal mammogram
_____ Lump under arm _____ Nipple discharge-what color is it? ___________
Female: # of pregnancies ______
Age at Menopause: ______
# live births ______
# of miscarriages ______
Age at first period: ______
Age at 1st Pregnancy: ______ Last Menstrual Period: _____________
How long have you had this problem?________________________________________________________________________
How severe is the problem? _________________________________________________________________________________
Have you had a recent mammogram? ____Yes ____No
Date: ______________ Where: ___________________________
Have you had a recent breast ultrasound? ____ Yes ____ No Date: _______________ Where: _______________________
Names of doctors? Primary Care: ____________________________OB/GYN: _______________________________________
PA/Nurse Practitioner: __________________________________ Medical Oncologist: __________________________________
Radiation Oncologist: ___________________________________ Cardiologist: ________________________________________
Medications:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Allergies to medications: ___________________________________________________________________________________
Medical History: Anemia _____ Asthma _____ Bleeding Disorders______Bowel Disorders_______Coronary Disease ________
Diabetes ____ Gallstones _____Heart Disease_____ Hereditary Defects_____High Blood Pressure_____High Cholesterol______
Kidney Disease ______Pneumonia ______ Rheumatic Fever______ Seizure / Convulsions______Stroke _____Tuberculosis ____
Ulcer Disease ______ Other __________________________________________________________________
Previous Hospitalizations / Surgeries / Serious Illnesses or Injuries:
Reason:
Date:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Patient Name: ______________________________________________________ Birthdate: ___________________________
Previous Breast Surgery?
Yes _____ No _____
Side: Right __________ Left ___________
Needle Biopsy ___________________ Surgical Biopsy _____________ Mastectomy ___________ Lumpectomy _____________
Benign ___________ Malignant ________ Date: _____________________ Where: ___________________________________
Patient history of previous Breast Cancer?
If yes, what type of treatment?
Yes ____________ No _________
Mastectomy: Left _________ Right _________ Bilateral __________
Lumpectomy: Left _________ Right _________ Bilateral __________
Radiation Therapy: Yes ________ No ______
Chemotherapy Treatment: Yes______ No ______ Type: ____________________ Length: ___________________________
Marital Status: M _____ S ______ D ______ W ______ Separated ___________
Use of Alcohol:
Use of caffeine:
Never _____ Rarely ______ Moderate ______ Daily __________
Yes _____ No _______ How much?
Use of tobacco: Never ________ Previously _____ How long ago did you quit? ______ Current packs per day: ____________
Use of drugs: Never ________ Type / frequency: _______________________________________________________________
Family History and who?
Obesity: _________________________________________________________________________________________
Arthritis: ________________________________________________________________________________________
Heart Disease: ____________________________________________________________________________________
Stroke: __________________________________________________________________________________________
Diabetes: _________________________________________________________________________________________
Cancer: Breast Cancer: (Who) ________________________________(what age) _______________________________
Ovarian Cancer: (Who) _______________________________ (what age) ______________________________
Colon Cancer: (Who) ________________________________ (what age) ______________________________
SYSTEM REVIEW:
Patient Name: ___________________________________
Constitutional:
Fever:
Yes___ No___
Chills:
Yes ___ No___
Weight Loss:
Yes ___ No ___
Weight Gain:
Yes ___ No ___
Fatigue:
Yes ___ No ___
Night Sweats
Yes ___ No ___
Loss of Appetite: Yes ___ No ___
EYES:
Change in Vision:
Blurred Vision:
Double Vision:
Eye Pain:
Cataracts:
Yes ___ No ___
Yes ___ No ___
Yes ___ No ___
Yes ___ No ___
Yes ___ No ___
HEENT:
Nasal Congestion: Yes ___ No ___
Headaches:
Yes ___ No ___
Lightheadedness: Yes ___ No ___
Dental Problems: Yes ___ No ___
Neck Pain:
Yes ___ No ___
Recent Head Injury: Yes ___ No ___
Hearing Loss
Yes ___ No ___
Dizziness:
Yes ___ No ___
Sore Throat:
Yes ___ No ___
Swollen Glands
Yes ___ No ___
Mouth Sores:
Yes ___ No ___
BREASTS:
Breast Lumps:
Yes ___ No ___
Breast Tenderness: Yes ___ No ___
Swelling:
Yes ___ No ___
Nipple Discharge: Yes ___ No ___
Breast Pain:
Yes ___ No ___
Lump-arm pit:
Yes ___ No ___
Nipple Pulling:
Yes ___ No___
Rash:
Yes ___ No ___
Dimpling of Skin: Yes ___ No___
CARDIOVASCULAR:
Chest Pain:
Yes ___ No ___
Irregular Heart Beat: Yes ___ No ___
Rapid Heart Rate: Yes ___ No ___
Palpitations:
Yes ___ No ___
Fainting Episodes Yes ___ No ___
Heart Murmurs:
Yes ___ No ___
Leg Pain:
Yes ___ No ___
Shortness of Breath: Yes ___ No ___
Lightheadedness:
Yes ___ No ___
RESPIRATORY:
Shortness of Breath: Yes___ No ___
Wheezing:
Yes ___ No ___
Cough:
Yes ___ No ___
Sputum Production: Yes ___ No ___
Hoarseness:
Yes ___ No ___
Anesthetic Problems: Yes ___ No ___
TB Exposure:
Yes ___ No ___
Asbestos Exposure:
Coughing Blood:
GASTROINTESTINAL:
Abdominal Pain:
Heartburn:
Nausea:
Vomiting:
Bloating:
Change in Abdominal Girth:
DOB: ______________________
Yes___ No ___
Yes ___ No___
Yes ___ No ___
Yes ___ No ___
Yes ___ No ___
Yes ___ No ___
Yes ___ No ___
Diarrhea:
Constipation:
Obstipation:
Jaundice:
Blood or Mucous in Stools:
Yes ___ No ___
Yes ___ No ___
Yes ___ No ___
Yes ___ No ___
Yes ___ No ___
Yes ___ No ___
Hemorrhoids:
Black Stools:
Yes ___ No ___
Yes ___ No ___
GENITOURINARY:
Painful Urination:
Urgency:
Frequency:
Incontinence:
Irregular Menses:
Hot Flashes:
Possible Pregnancy:
Blood in Urine:
Kidney Stones:
Yes ___ No ___
Yes ___ No ___
Yes ___ No ___
Yes ___ No ___
Yes ___ No ___
Yes ___ No ___
Yes ___ No ___
Yes ___ No ___
Yes ___ No ___
INTEGUMENT:
Rash:
Yes ___ No___
Itching:
Yes ___ No ___
New Skin Lesions:
Yes ___ No ___
Changes in Existing Lesions:
Yes ___ No ___
NEUROLOGIC:
Headaches:
Yes ___ No ___
Tingling or Numbness:
Yes ___ No ___
Muscular Weakness:
Yes ___ No ___
Incoordination:
Yes ___ No ___
Difficulty Concentrating:
Yes ___ No ___
Memory Problems:
Yes ___ No ___
Speech Problems
Yes ___ No ___
Seizures:
Yes ___ No ___
Tremors:
Yes ___ No ___
Loss of Balance:
Yes ___ No ___
Paralysis:
Yes ___ No ___
MUSCULOSKELETAL:
Bone Pain:
Yes ___ No__
Back Pain:
Yes ___ No__
Joint Pain:
Yes __ No__
Muscle Pain:
Yes __ No __
Joint Swelling: Yes __ No __
Limitation of Motion:
Yes __ No __
Muscular Weakness:
Yes __ No __
Muscle Cramps Yes __ No __
ENDOCRINE:
Loss of Hair:
Yes __ No __
Constipation:
Yes __ No __
Cold Intolerance Yes __ No __
Heat Intolerance: Yes __ No __
Acne:
Yes __ No __
Sexual Dysfunction:
Yes __ No __
PSYCHIATRIC:
Anxiety:
Yes __ No __
Depression:
Yes __ No __
Hallucinations: Yes __ No __
Delusions:
Yes __ No __
Feeling Confused:Yes __ No __
Difficulty SleepingYes__ No__
Compulsive Behaviors:
Yes __ No__
Suicidal Ideation: Yes __ No __
Excessive Anger: Yes __ No __
Personality Change Yes__No__
HEME-LYMPH:
Easy Bleeding:
Yes __ No__
Easy Bruising:
Yes __ No__
Lymph Node Enlargement or
Tenderness:
Yes __ No __
Lightheadedness: Yes __ No __
Recurrent Infections:
ALLERGIC IMMUNOLOGIC
Sinus Allergy Symptoms:
Yes __ No __
Allergic Dermatitis:
Yes __ No __
Frequent Illnesses:
Yes __ No __