New Patient Health Concerns Form Date MM slash DD slash YYYY Name(Required) First Last Email(Required) YOUR CURRENT AGE:(Required)Date of Birth(Required) MM slash DD slash YYYY WHY ARE YOU HERE?(Required) Routine/Follow Up breast lump Breast Cancer abnormal mammogram second opinion other DO YOU PRACTICE SELF EXАМ?BRA CUP SIZE?Your HeightYour WeightYour Blood PressureHAVE YOU EVER HAD BREAST LUMPS IN THE PAST?BREAST BIOPSY?HOW OLD WERE YOU WHEN YOU FIRST STARTED HAVING MENSTRUAL CYCLES?HAVE YOU HAD CHILDREN?NUMBER?YOUR AGE AT FIRST LIVE BIRTH?DID YOU BREAST FEED?HOW LONG?HAVE YOU HAD ANY BREAST INFECTIONS, INJURY OR TRAUMA?DO YOU HAVE ANY NIPPLE DISCHARGE?WHAT COLOR?APPROXIMATE DATE OF LAST KNOWN MENSTRUAL PERIOD:HAVE YOU EVER TAKEN BIRTH CONTROL PILLS?WHEN & HOW LONG?HAVE YOU TAKEN HORMONES?WHICH ONES & HOW LONG?IS THERE ANY FAMILY HISTORY OF BREAST CANCER?If so, Please list below which relatives and at what age where they. (e.g. Maternal aunt breast cancer 65 y/o)Is there a family history of ovarian Cancer?If so, Please list below which relatives and at what age where they. ANY OTHER CANCERS OR TUMORS?HAVE YOU HAD ANY MAMMOGRAMS IN THE PAST?APPROXIMATE DATES:LIST ALL PREVIOUS OPERATIONS YOU HAVE HAD:LIST ANY HOSPITALIZATIONS YOU HAVE HAD:Do you have any allergies?If so, please list what allergies and to which medications.MEDICATIONSCURRENT MEDICATIONSPlease List Name of Medicine, Dose in MG and How many times a day:NON-PRESCRIPTION MEDICINESPlease List Name of the NON-PRESCRIPTION Medicine, Dose in MG and How many times a day:Do you take GLP-1, autoimmune or similar weight loss medications? Yes No Do you take blood thinners or daily aspirin? Yes No ALLERGIES TO MEDICINESNAME OF ALLERGIC MEDICINEWrite Down TYPE OF ALLERGIC REACTION, OTHER ALLERGIES? LATEX? IODINE? TAPE?CURRENT SMOKER or tobacco user?FORMER SMOKER?NEVER SMOKED?As a patient at our office, we would like to inform you that your total health is important to us. Notice to all our new and existing patients: If you are a current tobacco user, we are obligated to inform you that smoking is harmful to your health and inhibits wound healing. For best results after surgery, it is recommended that you seek help with smoking cessation prior to any surgery. Please consult with your primary care doctor for assistance and resources with smoking cessation.Calculations (for office use):
