Clinical Breast Exam Form
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1CANCER SERVICES PROGRAM CLINICAL BREAST EXAM FORM
Name:__________________________________________ DOB: _________ Date:__________
Last
First
MI
MM/DD/YR
MM/DD/YR
Review of Patient History
Patient noticed changes in breasts since last visit?
Site code
No ___ Yes ___ Describe________________________________________________________
Patient has a personal or family history of breast cancer?
No ___ Yes ___ Who?__________________________ What age?_______________________
Patient noted spontaneous nipple discharge?
No ___ Yes ___ Describe________________________________________________________
Visual Exam:
Skin:
Normal/Benign
Scar(s)
Dimpling
Other:__________________________
Nipples:
Everted
Inverted
Retraction
Physical Exam:
Right
Left
Lymph Nodes
+
-
+
-
12
12
(Axillary/Clavicular)
Diagram Documentation Codes
9
3
9
3
Scar
Nodularity
Mole
*
*
Fibrocystic Area
Node
Dimpling
Mass
6
6
R
L
Describe all clinical exam findings, including NORMAL and ABNORMAL
(indicate size, shape, mobility, location of palpable findings).
Findings:_____________________________________________________________________
_____________________________________________________________________________
Plan: ________________________________________________________________________
Referral:
No _____
Yes _____
(explain)__________________________________
Breast Findings: Check one box only
1. Normal, Benign, Fibrocystic – Rescreen in 1-2 Years
2. Probably Benign – Repeat Exam in 3-6 months
3. Mass or Other Findings – Immediate Testing
_____________________________________________________________________________
Name of Examiner (please print)
_____________________________________________________________________________
Signature of Examiner
Date
This report should be maintained as part of the patient medical record.
05/22/09
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