COLUMBIA-PRESBYTERIAN EASTSIDE RADIOLOGY BREAST IMAGING HISTORY FORM
If you would like to purchase a CD with your mammogram on it, please inform the front desk ($35).
NAME DATE
DATE OF BIRTH AGE PHYSICIAN(S)
TO RECEIVE
REPORTS
DAY PHONE EVENING PHONE
E-MAIL YOUR ADDRESS
Could you be pregnant? Yes No Inform the technologist if you are or think you may be pregnant.
How do you prefer to be contacted, if it should be necessary?
Have you had a breast physical exam (not mammogram) by a doctor, nurse, or PA within the past 12 months? Yes No
Have you had a mammogram before? Yes No When? Where?
Please circle ROUTINE or RIGHT (R) or LEFT (L)
BREAST HISTORY - Have you ever had
Reason for today's mammogram:
ROUTINE
( ) breast cancer
R
L date
I feel a lump.
R
L
( ) breast biopsy
R
L date
I feel a thickening.
R
L
result
My doctor feels something.
R
L
( ) cyst aspiration
R
L date
Nipple discharge.
R
L
( ) cyst removed
R
L date
New nipple change.
R
L
( ) breast reduction
R
L date
Pain
R
L
( ) abscess treated
R
L date
Follow something on prior
R
L
( ) breast implant
R
L date
Last menstrual period If you have stopped having periods, at what age did they stop?
Have you had your ovaries removed? YES NO YEAR
Have you had ovarian carcinoma? Yes No
HORMONE USE
Have you ever used female hormones (including vaginal creams, suppositories, or patches) such as estrogen? YES NO
If you have, between what ages? to Are you presently using them? YES NO
FAMILY HISTORY (Please indicate age at which cancer was diagnosed)
Who has had breast cancer, and at what age?
Who has had ovarian carcinoma, and at what age?
BREAST CANCER TREATMENT (Please circle)
Have you had a mastectomy or lumpectomy? YES NO If so, which side? RIGHT LEFT
Have you ever had radiation therapy to your breasts? YES NO If yes, when?
Have you ever had chemotherapy for breast cancer? YES NO If yes, when?
result 
