Patients Name: _________________________________________
Age: ________________ DOB: ________________
1. Your Height? __________ Weight? __________
2. What size bra do you wear? __________
3. What size would you like to be? ___________
4. How many children do you have? __________ Ages? ___________
5. Breast feed? ______Yes ______No How many children? _________
6. Did your breast change size with pregnancy? ______Yes ______ No
7. If yes, how much in bra size? _______________________________
8. Have you ever had a mammogram? ________ Yes _________ No
9. If yes, when? ____________________________________________
10. Any breast disease or tumors? _____________________________
11. If yes, explain? _________________________________________
12. Has anyone in your family had any breast diseases or tumors? _____ Yes _____No
13. If yes, explain? _________________________________________
14. Are you using any form of birth control? _______Yes _________No
15. If yes what form? _______________________________________
INFORMATION BELOW TO BE FILLED OUT BY OFFICE ONLY
NEEDS PRE-OP MAMMOGRAM____________YES ______________No