1860 Pennsylvania Avenue, Suite 200

Fairfield, CA 94533
(707) 646-4180

This form was designed to reduce the duplication of medical histories taken by many of the physicians you may
encounter in the course of your breast care. Please complete the following questions using a blue or black pen.
Leave questions blank if you are unsure how to answer the question; a medical staff member will be reviewing
the form with you before you see the physician. Thank you for taking the time to fill out this form.

Ethnic Origin
 Asian American  African American  Caucasian  Hispanic  Ashkenazi Jewish Ancestry
 Other _________________________

Referral Information

Who referred you to our office?  Doctor  Family  Friend  Self  Internet
Please specify the person’s name (if applicable): _________________________________________

Main Reason for Visit (please check only one)

 Abnormal mammogram  Breast Pain  Breast Lump  Other: ____________________
Breast lump, pain, or “other” first found by:  Me  Doctor  Mammogram

Are You Currently Having Any of the Following Problems?

1. Lumps in breast:  No  Right  Left  Bilateral Since when? ______
How did you find the lump? ___________________________________________________
2. Nipple discharge:  No  Right  Left  Bilateral Since when? _____
Method of detection:  Spontaneous  Expressed
Color:  Brown  Green  Red  Clear  White  ______
3. Breast tenderness/pain:  No  Right  Left  Bilateral Since when? _____
My breast pain is:  Continuous  On and Off
4. Breast redness or swelling:  No  Right  Left  Bilateral Since when? _____
5. Prior breast injury:  No  Yes
6. Other complaints: ______________________________________________________
__________________________________________________________________
__________________________________________________________________

Last Name, First

Med Rec# PCP

BREAST HEALTH
QUESTIONNAIRE
DOB: Age __________ SC-02 Rev. 10/12

PATIENT ID STICKER
Mammography Information
Have you had a previous mammogram?  No  Yes: Where? __________ When? ___ / ___ / _____
Date of your first mammogram: ___ / ___ / _____
Do you practice monthly breast self-exams?  No  Yes  Sometimes

Ob/Gyn History
1. Have you had a hysterectomy?  No  Yes: Date of surgery: ___ / ___ / _____
Have your ovaries been removed?  No  One  Both  Unsure
2. Date of most recent pelvic exam: ___ / ___ / _____
3. Are you pregnant?  Unsure  No  Yes: Due date - ___ / ___ / _____
4. Age at first menstrual cycle: ____
5. Are you still having periods?  No  Yes
6. Beginning date of last menstrual cycle: ___ / ___ / _____
7. Which option best describes you:
 Have not had menopause yet  Currently undergoing menopause
 Not sure if I have undergone menopause
 Already underwent menopause at age _____ Type of Menopause:
 Natural (periods just stopped by themselves)
 Surgical (ovaries and/or uterus removal)
8. Number of pregnancies: _____ Live-births: _____ Miscarriages/Abortions: _____
9. Age at first birth: _____ Age at last birth: _____
10. Did you ever breast feed?  No  Yes
Age at first breast feeding: _____ How long (All the children together) ? _______ months

Hormonal Medical History

1. Birth control pills:  Never used  On and Off use  One long continuous period of use
Age started: _____ Total years used: _____ Currently taking birth control pills?  No Yes
2. Hormone replacement therapy:  Never used  On and Off use  One long continuous period of use
Age started: _____ Total years used: _____ Are you currently taking hormones?  No  Yes
3. Infertility drugs/hormones:  Never used  On and Off use One long continuous period of use
Age started: _____ Age stopped: _____ Total months used: _____

Breast Surgery/Treatment History

1. Have you ever had a breast cyst(s)?  No  Right  Left  Both
(Cysts are little sacs of fluid that are sometimes drained with a needle or may be seen on a mammogram or
ultrasound.)

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2. Number of needle biopsies you have had:  None  Right _____ Left _____
(Needle biopsies are done in the office or in the breast imaging area.)
Type of needle biopsy:  FNA  Core  Unsure

3. Number of surgical biopsies you have had:  None  Right _____  Left _____
(These involve cutting into your skin and are usually done in the operating room.)
Did the pathology show ADH (atypical ductal hyperplasia)?:  No  Yes Unsure
Did the pathology show LCIS (lobular carcinoma in situ)?:  No  Yes  Unsure
Age when first diagnosed with LCIS: _____
4. Have you ever been diagnosed with breast cancer?  No  Right  Left  Both
If yes, what type of surgery have you had for breast cancer?  Removal of part of the breast
 Removal of the whole breast
Did you have reconstruction of the breast?  No  Yes
5. Have you ever had breast implants?  No  Yes: If yes, do you currently have implants?  No  Yes
Have you ever had silicone implants?  No  Yes
Any trouble with leaking implants?  No  Yes

Your Health History

1. Height: _____ feet _____ inches Weight: _____ pounds
2. Do you have a history of cancer other than breast cancer?  No  Yes
3. Have you ever had radiation therapy?  No  Yes
4. Have you ever had chemotherapy?  No  Yes
5. Do you have rheumatoid arthritis, lupus, Raynaud’s or scleroderma?  No  Yes
6. Have you ever tested positive for AIDS or HIV?  No  Yes
7. Have you ever had general anesthesia?  No  Yes  Unsure
If yes, were there any problems?  No  Yes
Do you have any family history of anesthesia problems?  No  Yes
8. Do you have any bleeding problems?  No  Yes
Are you taking any blood thinners?  No  Yes
Are you on daily aspirin?  No  Yes
9. Marital Status:  Single  Married  Divorced  Widow
10. Highest level of education:  High School  Some College  College Degree
11. Current employment status:  Employed  Retired  Disabled  Unemployed
Occupation: _________________________________________________________
Occupational toxin exposure history: _________________________________________
12. Caffeine (Regular use):  coffee: _____ cups per day / week / month (circle one)
 NONE  tea: _____ cups per day / week / month (circle one)
 soda: _____ cans per day / week / month (circle one)
 chocolate bar: _____ # per day / week / month (circle one)

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13. Alcohol use:  No  Yes  Occasionally (Less than 1 drink per week)
If yes, how many drinks per week? _____ Beer: _____ Wine: _____ Hard liquor: _____
14. Tobacco use (ever):  No  Yes  Sporadic use
If yes, type:  Cigarette  Cigar  Pipe  Snuff  Previous smoker
For cigarette smokers: _____ packs/day for _____ years
15. Have you ever taken street/recreational drugs?  No  Yes: specify - __________________

Current medications and doses: _______________________________________________

____________________________________________________________________
____________________________________________________________________
Drug or food allergies and reactions: ____________________________________________
____________________________________________________________________
____________________________________________________________________
List all previous surgeries and dates: ____________________________________________
____________________________________________________________________
____________________________________________________________________
List any medical problems and when they were diagnosed: ______________________________
____________________________________________________________________
____________________________________________________________________

Family History
Please list all relatives including yourself, sons, daughters, mother, father, sisters, brothers, maternal and paternal aunts and
uncles, and grandparents. Please include any major medical problems and, if they were diagnosed with cancer, ther age at
that time. Circle “Living” or “Deceased” and note the current age, or age at death. If you are adopted, only include your
family members that are genetically related to you.

Relationship Living or Age Major Medical Problems Type of Cancer(s) &

Deceased Age at Diagnosis

Daughter / Son Living

Deceased

Daughter / Son Living

Deceased

Daughter / Son Living

Deceased

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Mother Living

Deceased

Father Living

Deceased

Sibling Living

Deceased

Sibling Living

Deceased

Maternal Living
Grandmother
Deceased

Maternal Living
Grandfather
Deceased

Maternal Aunt / Living

Uncle
Deceased

Maternal Aunt / Living

Uncle
Deceased

Paternal Living
Grandmother
Deceased

Paternal Living
Grandfather
Deceased

Paternal Aunt / Living

Uncle
Deceased

Paternal Aunt / Living

Uncle
Deceased

(If additional space is needed, please write on back of this page in same format.)

Page 5 of 7 SC-02: Breast Health Questionnaire

I have fully reviewed the questionnaire and answered all questions truthfully and to the best of my
knowledge. I am aware that my answers could affect my health care, or that of the patient for whom I am
responsible:

______________________________________ _____ / _____ / _________

Patient Signature Date

______________________________________
Relationship (if signature of parent or guardian)

I have read and reviewed these results with the patient or responsible party.

______________________________________ _____ / _____ / _________

Physician’s Signature Date

Page 6 of 7 SC-02: Breast Health Questionnaire

 REVIEW OF SYMPTOMS
Please review and check the appropriate box for any problems you may have now, or had in the past.

General Gastro-Intestinal Neurological

Unable to exercise Stomach Ulcers Nerve Injury
Weight Loss Duodenal Ulcers Paralysis
Planned Weight Loss Hepatitis Headaches
Weight Gain Nausea Stroke
No recent weight gain/loss Diarrhea Seizure
Radiation Tx Blood in Stool Migraine Headaches
Cancer Chemotherapy Heartburn Speech Problems
Vomiting Balance Problems
Constitutional Change in Bowel Habits Fainting/Blackouts
Fever Colitis TIA
Night Sweats Vomiting Blood
Loss of Appetite Intestinal Ulcers Rheumatoid
Liver Problems Rheumatic Fever
Infection Jaundice Back Injury
Recent Cold/Flu Hiatal Hernia Neck Injury
Tuberculosis Hemorrhoids Herniated Disc
Constipation Arthritis
Mouth/Throat Irritable Bowel Syndrome Rheumatoid Arthritis
Dental problems
Mouth Ulcers Genito-Urinary Musculoskeletal
Gum Bleeding/Pain Kidney Problems Leg cramps/pain
Hoarseness Nephritis Weakness
Difficulty Swallowing Kidney Stone Muscle Aches
Blood in Urine Osteoporosis
Cardiac Hot Flashes Scoliosis
Heart Attack Frequent Urination
Heart Disease Vaginal Discharge Psychiatric
High Blood Pressure UTI Depression
Heart Murmur Incontinence of Urine/Stool Mental Problems
Angina Vaginal Spotting Sleep Problems
Irregular Heart Beats Sexual Problems Anxiety
Short of Breath Burning on Urination
Palpations Oro-Gastric
Mitral Valve Prolapse Hematological/Lymphatic Esophageal Ulcers
Heart Failure Bleeding Tendency
Tachycardia Hemophilia Eyes/Ears/Nose
Pericardial Effusion Easy Bruising Sinus Disease
Pacemaker Anemia Cataracts
Aneurysm Lymphoma Recent Visual Change
Leg/Food Edema Blood Transfusion Nose Bleeds
Premature Ventricular Leukemia Double Vision
Contractions
Blood Clots Ringing in Ears
Respiratory Red Cell Problems Hearing Loss
Chest Pain Platelet Problems
Asthma Anticoagulants Skin
Chronic Cough Enlarged Lymph Nodes Rashes
Pneumonia Sores
Bronchitis Endocrine Pigmented Moles
Breathing Problems Thyroid Problems Hives
Wheezing Steroid Use Skin Ulcers
Emphysema Intolerance to Heat/Cold
Short of Breath Diabetes
Pleurisy Diabetes (Gestational)

Page 7 of 7 SC-02: Breast Health Questionnaire