Breast Exam Record
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1Breast Self-Examination Record
Left Breast
Right Breast
Date of
Problem /
Notes
Date of
Problem /
Notes
Exam
Concern
Exam
Concern
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If you notice any of the following conditions during your self-examination, note the details
for discussion with your doctor:
Lump(s)
Dimpling
Redness
Tenderness
Nipple discharge
Puckering
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