New Patient Health Concerns Form Date MM slash DD slash YYYY Name First Last YOUR CURRENT AGE:Date of Birth MM slash DD slash YYYY WHY ARE YOU HERE? 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.Calculations (for office use):REVIEW OF SYSTEMS Do you now or have you had ANY MAJOR PROBLEMS related to the following systems? Please select Y (Yes) or N (No) and explain any YES answer in the space provided.Constitutional SymptomsFever Yes No Chills Yes No Headache Yes No Explain Any YES AnswerIntegumentarySkin Rash Yes No Boils Yes No Persistent Itch Yes No Explain Any YES AnswerEyesBlurred Vision Yes No Double Vision Yes No Eye Pain Yes No Explain Any YES AnswerMusculoskeletalJoint Pain Yes No Neck Pain Yes No Back Pain Yes No Explain Any YES AnswerCardiovascularChest Pain Yes No Varicose Veins Yes No High Blood Pressure Yes No Explain Any YES AnswerEar/Nose/Throat/MouthEar Infections Yes No Sore Throat Yes No Sinus Problems Yes No Explain Any YES AnswerNeurologicalTremors Yes No Dizzy Spells Yes No Numbness/Tingle Yes No Explain Any YES AnswerGenitourinaryUrine Retention Yes No Painful Urination Yes No Urinary Frequency Yes No Explain Any YES AnswerEndocrineExcessive Thirst Yes No Too Hot/Cold Yes No Tired/Sluggish Yes No Explain Any YES AnswerRespiratoryWheezing Yes No Frequent Cough Yes No Short of Breath Yes No Explain Any YES AnswerAllergic/lmmunologicHay Fever Yes No Drug Allergies Yes No Explain Any YES AnswerHematological/LymphaticSwollen Glands Yes No Blood Clotting Yes No Explain Any YES AnswerGastrointestinalAbdominal Pain Yes No Nausea/Vomiting Yes No Indigestion/heartburn Yes No Explain Any YES AnswerPsychologicalAre you dissatisfied w/your life? Yes No Do you feel severely depressed? Yes No Do you use recreational drugs? Yes No Explain Any YES Answer
