Sagoff Breast Imaging & Diagnostic Centre ... - Faulkner Hospital

Sagoff Breast Imaging & Diagnostic Centre
Brigham and Women’s Faulkner Hospital
Breast Imaging Questionnaire
Name: _____________________________
DOB: ___________________________
PLEASE INFORM STAFF MEMBER IF YOU ARE
PREGNANT OR MAY BE PREGNANT
Reason for today’s exam: Routine Breast problem
Please list phone numbers at which we can contact you, if necessary:
PATIENT INFORMATION: Home: Work:
Please complete both sides of this form Cell: Email:
CURRENT SYMPTOMS NONE FAMILY HISTORY OF BREAST CANCER NONE
Right Left Mother Age at diagnosis____________________
Persistent Breast Pain of Concern. How long _______ Sister Age at diagnosis____________________
Lump, felt by patient Date: _________ Daughter Age at diagnosis____________________
Lump, felt by physician Date: _________ Other(s) Age at diagnosis____________________
Nipple discharge clear bloody other
Nipple changes New Chronic
Breast infection/Abscess Date:__________ CURRENT MEDICATIONS:
Recent breast MRI Date: Facility: Hormone:
Estrogen
PREVIOUS BENIGN PROCEDURES NONE Progesterone
Right Left
Tamoxifen
Cyst Aspiration Allergies: NONE
Reduction Year _____
Implants Year _____ Silicone Saline
Biopsy Year ______ Results ________________ MENSTRUAL HISTORY
Other Breast Surgery:__________________________ Date of last menstrual period:_________________
Age when menstruation stopped:_______________
HISTORY OF BREAST CANCER NONE
Natural Surgical
Right Left Is there a chance you are pregnant Yes No
Currently being treated for breast cancer Are you breast feeding Yes No
Lumpectomy Date: ____________ Please specify any weight gain//loss (e.g. +/- 15 pounds)
Mastectomy Date: ____________
Radiation Therapy Year Complete ______
PREVIOUS BREAST IMAGING (date, name of facility)
Reconstruction Type: ________ Mammogram: _______________________ NONE
Chemotherapy Yes No Date: _________ Ultrasound: _________________________
Hormone Therapy for Breast Conservation Yes No MRI: ______________________________
If yes, Start Date:________________
Stop Date:________________
PATIENT HISTORY OF CANCER (other than breast):
Type: ____________________________________________________________________________________
FOR OFFICE USE ONLY:
Age: ___________
Today’s Date: ________________________
TECHNOLOGIST COMMENTS:
No complaints
PLTE
No Visible No Moles No Skin Cysts
Priors in system: ______________________________________
Scar
Technologist Name:__________________________ ___________________________Date: ____/____/____ Time: ________
(Signature)
(Print Name)

Please list medications you are currently taking if you are scheduled for a procedure (i.e. biopsy, cyst
aspiration, wire localization):
Patient Choice
Applies only to patients scheduled for a screening mammogram Monday-Friday, before 4 p.m.
We know your time is valuable, and so we want to offer you a choice regarding how you receive your
mammogram results today 1 . Please choose the option that best meets your needs today by checking the
appropriate box below:
Screening mammogram, results mailed to you (Appointment time ~30-45 minutes)
Choose this option if you would like to leave after your screening mammogram is completed,
and we will mail your results letter to you within 7 days. If the Radiologist requests additional
diagnostic imaging 2 you will be called back for an additional appointment. If you are asked to
return for a diagnostic mammogram 3 , you will meet with the Radiologist during the appointment.
Screening mammogram, results given same day (Appointment Time ~60-90 minutes)
Choose this option if you would like to receive your results today. A staff member will give you
a results letter after the Radiologist has read your exam. If you wish to meet with the Radiologist
who read your exam, please inform a staff member at any time during the course of your visit. If
a Radiologist requests additional diagnostic imaging 2 , the exam will be completed today 3 .
Note to Patient:
(1) On the day of your annual screening mammogram appointment, if you present with a lump or any other sign
or symptom of breast disease, a diagnostic mammogram will be performed instead of a screening mammogram.
(2) Approximately 10% of patients having a screening mammogram will have additional views, also known as
a diagnostic mammogram, requested by a Radiologist. Diagnostic mammograms, and sometimes breast
ultrasound, are obtained when the radiologist needs to further evaluate a potential abnormality. Appointments
may be longer than the stated time above if additional imaging is needed.
(3) Though insurance companies will cover a screening mammogram, you may be responsible for charges
associated with a diagnostic mammogram or breast ultrasound. We encourage you to contact your insurance
carrier in advance of your screening appointment to determine whether or not diagnostic mammograms and
breast ultrasound are covered services.
Are you dizzy or weak today Yes No
Do you walk with assistance Yes No
Have you had any recent falls Yes No
______________________________________________________________________________________
Please sign and date
(Date)
Thank you.
05/13