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Name

Date: ___________________ Name _____________________________________________ Sex: Female Male Last First Date of Birth: ________________ Age: _______ Social Security # ______- ______- ________ Home Address________________________________________________________________________
e-Mail Address_______________________________________________________________________
Home Phone (___)____________________ Cell Phone (___)_________________________________
Business Phone (_ ___)________________ The preferred phone is H C B
Emergency contact: ____________________________________ Relationship ____________________
Address _____________________________________________ Phone: (_____)___________________
PCP:
1). Name: ___________________________________________ Phone: (_____)___________________
Address: _________________________________________________________________________
Referring Physician:
2). Name: __________________________________________ Phone: (_____)___________________
Address: ________________________________________________________________________
Periodic reports may be sent to your Physicians. To which of the above would you like these reports
sent?
1). ________________________ 2). ______________________ 3). _____________________
We would like to know how you selected this practice:
 My Physician recommended I come  I asked my physician to refer me  I referred myself  A friend or relative referred me Other: ________________________________________________
REASON FOR SEEKING CARE

1. Check one. Right Left Bilateral
 Lump in breast, don’t recall who found it At approximately what date did this symptom (including abnormal mammogram) become apparent to you? 2. Were there any other problems? Choose all that apply.  Lump in breast, don’t recall who found it

SMOKING AND ALCOHOL HISTORY

3. Have you ever smoked?
 Yes; currently____________________packs per day, since__________________________ 4. Have you ever or do you currently drink alcohol?  Yes; currently___________________drinks per week, since_________________________ GYNECOLOGIC HISTORY
5. At what age did you have your first period?
6. How many times have you been pregnant? 7. How many live births have you had? 8. a. If you have children, what was your age at your first time full term pregnancy? 8. b. If you have children, what was your age when you had your last full term pregnancy? 9. Have you had a menstrual period within the last six months?  Yes, natural menstrual periods or menstrual periods on birth control pills  Yes, have menstrual periods on hormone replacement therapy 10. When was your last menstrual period? _______/_______/______ 11. If you have NOT had a menstrual period within 6 months, why did your periods stop?  Both ovaries removed, no hysterectomy  Hysterectomy with both ovaries removed 12. If you have not had a period within the last 6 months, at what age did you stop having periods? Or, if both ovaries have been removed, how old were you when they were removed? 13. If both ovaries have been removed, what was the date of surgery (month/year)? 14. Have you ever used, or do you use, estrogen or estrogen replacement therapy? Do NOT include birth control pills. 15. If you used estrogen currently or in the past, what form of estrogen do/did you use? Check ALL that apply. 16. How many total years have you used estrogen replacement? 17. a. Do you use, or have you ever used, birth control pills? b. If so, for how many years? Years 18. Have you ever used fertility drugs?  Yes  No (If no, skip to question 19) a. If yes, have you used Clomiphene citrate (i.e. Serophene, Clomid)? b. If yes, have you used an injectable hormone (i.e. hMG, Gonal-F, Follitism)?  Yes  No (If No, skip to question 20) b. If yes, how many months (in total) have you breastfed? Months c. If yes, how many years (or months) ago did you last breastfeed? Months or years (please circle) 20. What was the approximate date of your last pelvic exam (internal female exam)?
MEDICAL HISTORY
21. Do you now have, or have you ever had any of the following? Please provide details.

A stroke, blood clot/bleeding in the brain, TIA? Alzheimer’s Disease, or another form of dementia? Hepatitis, Cirrhosis, or serious liver damage? Cancer (other than breast cancer)?
Other medical conditions not mentioned above and details
PAST SURGERY/OPERATIONS

22. PLEASE LIST IN CHRONOLOGICAL ORDER:

MONTH

OF REASON FOR HOSPITAL
OPERATION

MEDICATIONS
23. Please list any medications you are now taking:
24. Please list or describe any other therapies, vitamins or herbal remedies you are taking currently, why & how you take each (such as frequency and amount). If you need more space, continue on back. Name of vitamin, herb or therapy: ________________________________________________________________________________
____________________________________________________________________________


ALLERGIES

25. Are you allergic to any medicines?  Yes  No
*If so, please list any medications to which you have had an allergic reaction, and the type of reaction: 26. Are you allergic to any foods? *If so, please list any foods to which you have had an allergic reaction, and the type of reaction:
FAMILY HISTORY

Please include only blood relatives, both living and deceased.
27. How many sisters do you have?
28. How many brothers?
29. How many daughters?
30. How many sons?
31. Do you have any blood related family relatives who have been diagnosed with cancer? If yes, please use the chart below to indicate their relationship to you, the type of cancer they have, their age at diagnosis, and whether or not they are still living. Please print the type of relative in the Relative column and the type of cancer in the Cancer Type column* NOTE: If you have more than one relative of a particular type who has been diagnosed with cancer, please assign each a number in the Relative column (e.g. sister 1 and sister 2) Blood Relative SAMPLE*: Mother
* For example, if your mother was diagnosed with breast cancer at age 63 and she is still living, you would print Mother in the Relative column, Breast Cancer in the Cancer Type column, 63 in the Age at Diagnosis column, and check off Yes in the alive column. If you only knew that she was diagnosed sometime in her 60's, you would print 60 in the Age at Diagnosis column and check off the Yes box in the Is Age Estimated to the Decade column. 32. Were any of your grandparents of Ashkenazi Jewish descent? 33. Have you been tested for the BRCA gene mutation? 34. If Yes what was the result:_________________________________________________________
PHYSICAL ACTIVITY
35. Which option below best describes your level of physical activity OVER THE PAST WEEK? Choose one.
 Fully active, able to carry on all usual activities without restriction  Restricted in strenuous activity; can walk; able to carry out light housework  Can walk and take care of self; up more than ½ day  Need some help in taking care of self, spend more than ½ day in bed or chair  Cannot take care of self at all and spend all my time in bed/chair

Source: http://reveszmd.com/udata/ckfinder/files/h&p_female_patient_form.pdf

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