Breast Mri Questionnaire
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1
2Breast MRI Questionnaire
Reason for Exam:
_____ Implants
_____ Dense tissue
_____ Breast lump – which breast? ______________________
_____ Breast pain – which breast? _______________________
_____ Nipple discharge – which breast? ___________________
_____ Known breast cancer – which breast? ________________
_____ Family history of breast cancer
Indicate the location(s) of any
lumps or painful areas
_____ Other: ___________________________________________________________
Prior Exams:
_____ Mammogram – If not here, where/when? ___________________________________
_____ Breast ultrasound – If not here, where/when? _______________________________
_____ Breast MRI – If not here, where/when? ____________________________________
Prior Breast Surgery:
Have you ever had any type of breast surgery?
□
Yes
□
No
If yes, what type of surgery did you have? __________________________________
When was it performed? ________________________________________________
Menstruation:
Are you still menstruating? □
Yes
□
No
If yes, when was the first day of your last menstrual cycle? _______________________
General:
Are you breastfeeding?
□
Yes
□
No
Are you taking or have you ever taken any hormones, including birth control?
□ Yes
□ No
If yes, what type? ___________________________________________________
If you no longer take them, when did you stop? ____________________________
History:
Do you have any family history of breast cancer?
□
Yes
□
No
If yes, please list which relatives: _________________________________________
Have you been tested for the breast cancer gene?
□
Yes
□
No
If yes, are you a carrier of the gene?
□
Yes
□
No
I attest that the answers I have provided on this form are true and correct to the best of my
knowledge.
Signature: _________________________________________ Date: _______________
Printed Name: _______________________________________
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