Breast Imaging Questionnaire

Breast Imaging Questionnaire
Please do not complete this form until it's less than one week before your appointment.
Patient's name*

First NameMiddle (optional)Last Name
Age*
Referring MD*
2nd MD to get report
Have you had a COVID vaccine/booster?*

YesNo
The vaccine can cause lymph node swelling under the arm for several weeks, which may require additional testing and/or follow-up.
Date of last vaccination/booster
Last vaccination/booster in which arm?

Right armLeft arm
Do you want a 3D mammogram? It's more accurate, has fewer false positives, and is covered by most insurances.*

YesNo
Where did you have your last mammogram?*

Weinstein Imaging AssociatesElsewhereThis is my first mammogram
Was your last mammogram within the past 2 years?

YesNo
Approximate year of your last mammogram
Approximate year of your last breast ultrasound
Where was your last breast MRI (Magnetic Resonance Imaging) test performed?*

Never had a breast MRIMageeAllegheny General HospSt. Clair Hosp
Approximate year of your last breast MRI
Do you have any new breast concerns?*

Yes (provide details below)No, I'm here for a routine screening mammogramNo, I'm here for follow-up of a finding on my last study
Check all breast concerns that you have: ***Please be sure to get a script from your doctor for a diagnostic mammogram and breast ultrasound.

I FELT a breast lumpMy doctor felt a breast lumpThickening in my breastBreast pain or tendernessInverted nippleNipple discharge or bleeding
Lump: Which breast and how long have you had it?
Thickening: Which breast and how long have you had it?
Pain or tenderness: Which breast and how long have you had it?
Inverted nipple: Which breast and how long have you had it?
Nipple discharge or bleeding: Which breast and how long have you had it?
Since your last mammogram, have you have any new breast surgery, breast biopsy, family members with breast or ovarian cancer, or breast cancer gene testing?

YesNo
Have you ever had breast surgery, implants, biopsy, or cyst drainage?*

YesNo
Check all that apply

Breast implantsBreast reduction or breast lift surgeryAspiration (drainage) of breast cystsBenign needle biopsy (not cysts)Benign surgical biopsy (not cancer)Atypical hyperplasiaLobular carcinoma in situBreast cancer
Describe implant type and year(s) of surgery
Reduction or lift: Which breast and in what year?
Cyst drainage: Which breast(s)?
Benign needle biopsy: How many biopsies in each breast?
Benign surgical biopsy: Which breast and in what year?
Atypical hyperplasia: Which breast and in what year?
LCIS: Which breast and in what year?
Breast cancer: Which breast and in what year?
Please describe your breast cancer and treatment

Invasive or infiltratingDCIS or intraductalHad mastectomyHad lumpectomyRadiation treatmentChemotherapyHormone therapy (e.g. tamoxifen, etc)
Do you have any of the following risk factors?*

Personal history of ovarian cancerOther cancersCurrently on hormone replacement therapy (HRT)Hormone replacement therapy (HRT) in the pastCurrently on birth control pillsAshkenazi Jewish heritageI was tested for a breast cancer geneOne of my relatives was tested for a breast cancer geneNone of the above
What other cancers have you had?
Type of HRT
How long have (had) you been on HRT?
If no longer taking HRT, how long ago did you stop?
What were your breast cancer gene test results?
Which relative was tested and what were the results?
Relatives with BREAST cancer*

NoneMotherSisterMaternal grandmotherPaternal grandmotherMaternal auntPaternal auntDaughter
At what age was your relative(s) diagnosed with breast cancer?
Relatives with OVARIAN cancer*

NoneMotherSisterMaternal grandmotherPaternal grandmotherMaternal auntPaternal auntDaughter
At what age was your relative(s) diagnosed with ovarian cancer?
Height*
Weight (pounds)*
Previous weight (at your last mammogram)
Menstrual periods started at age*
Enter NA if not applicable
Your age when you had your first baby*
Enter NA if not applicable
Menstrual status (choose most appropriate answer)*

I've gone through menopause (change of life)I'm perimenopausalI had hysterectomyI'm still having periods, but not pregnant to the best of my knowledgeI'm pregnant or possibly pregnant (please INFORM STAFF)
At what age did you have hysterectomy or go through menopause?
FIRST day of your last menstrual period

MonthDayYear
Do you have a known latex allergy?*

* YES *No
By submitting the information below, you are electronically signing this form.
Patient's name
Birth date*

MonthDayYear
Should be Empty:

Breast Imaging Questionnaire

Please do not complete this form until it's less than one week before your appointment.