Breast history survey

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.
Name (Last, First, M.I.): / ¨ M ¨ F / DOB: / Today’s Date:

Is this your first mammogram?

/ ¨ No ¨ Yes If no, where was your last mammogram?
Please include facility name, city, and state
Have you had any significant weight changes since your last mammogram? ¨ No ¨ Yes / If yes: ¨ Loss ¨ Gain Amount:

Are you or might you be pregnant?

/ ¨ No ¨ Yes / If yes, you must inform the technologist before your exam. /

Is this a screening or diagnostic exam?

/ ¨ Screening ¨ Diagnostic

PERSONAL HEALTH history

Are you experiencing any new breast concerns today, for example a new lump or abnormal discharge?

/ ¨ No ¨ Yes / If you stated yes, and your appointment is for a screening mammogram and you have a new lump or abnormal discharge, we may need to reschedule your appointment for a diagnostic exam.
If you are experiencing a breast concern, please check any that apply:
/ ¨ Lump / ¨ Left ¨ Right ¨ Both / ¨ Nipple discharge / ¨ Left ¨ Right ¨ Both
¨ Pain / ¨ Left ¨ Right ¨ Both / ¨ Skin changes / ¨ Left ¨ Right ¨ Both
¨ Other / ¨ Left ¨ Right ¨ Both / Please describe:

Have you ever had breast biopsies or surgeries, including but not limited to implants or reduction? ¨ No ¨ Yes

Year / Procedure / Side
¨ Left ¨ Right ¨ Both
¨ Left ¨ Right ¨ Both

Have you ever had breast cancer? ¨ No ¨ Yes

Year / Type / Side
¨ Left ¨ Right ¨ Both
¨ Left ¨ Right ¨ Both

How old were you when you had your first period?

/ Approximate or exact age:

Have you ever been pregnant? ¨ No ¨ Yes

/ How many times have you been pregnant?
If Yes: / How many children have you given birth to?
How old were you when you had your first child?

Have any of your blood relatives had breast cancer? ¨ No ¨ Yes ¨ Unsure/Don’t know

Family Member / Age

What is your ethnicity?

¨ White ¨ African American ¨ American Indian, Eskimo, Aleut ¨ Asian American ¨ Hispanic ¨ Chinese
¨ Japanese ¨ Filipino ¨ Native Hawaiian ¨ Asian ¨ Pacific Islander ¨ Other Race ¨ Decline to answer

We always send a letter regarding your results, and will call you if you need additional follow up.

Would you like a call with your results in addition to a letter?

¨ No ¨ Yes / If yes, please provide a phone number where we can leave a message:

Continued on the other side, please turn this page over and complete the form on the back.

Name (Last, First, M.I.):

/

Date of Birth:

I verify the information I have provided is true to the best of my knowledge. I give my permission to release any information to Corridor/Muscatine Radiology that pertains to or aids in the completion of today’s exam. This includes prior breast imaging such as ultrasound or mammography, and any past or future breast biopsies and pathology reports.
Patient Signature / Today’s Date:

To be completed by technologist

Please mail patient images and their reports to:

¨ / Muscatine Radiology
Attn: Mammography Dept.
2104 Cedarwood Dr. Suite 100
Muscatine, IA 52761 / Phone: 563-263-3400
Fax: 563-263-3311
¨ / Corridor Radiology
Attn: Mammography Dept.
2769 Heartland Dr. Suite 105
Coralville, IA 52241 / Phone: 319-545-7300
Fax: 319-545-7309

Please mail or fax any biopsy or pathology report to:

¨ / Corridor Radiology
Attn: Mammography Dept.
2769 Heartland Dr. Suite 105
Coralville, IA 52241 / Phone: 319-545-7300
Fax: 319-545-7309

Outside Facility Information

Name:
Address:
Phone:
Fax:
If you called the facility, name of person you spoke with:
Technologist completing this form:
Date release was faxed:

3/19/2017 CLD