Patient First NamePatient Last NameEmail Date of BirthMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Welcome to The Breast Center by Kansas Surgical Consultants. In order to provide the best care we need to know your medical history. Please take a few minutes to answer all questions. Please add any information you feel will help explain your health. If you need any help with this form please ask us. Thank youAgeHeightWeightBra SizeWho referred you to our practice?Have any of your family members been treated here? Yes NoWho is your family physician?Please list any other doctors you wish us to communicate with.Breast HistoryCheck the box if you have had: Breast Pain Breast Discharge A breast mass that you can feel Abnormal Mammogram A recent biopsy OtherPlease ExplainCheck all that apply to you: Breast cancer prior to age 50 Breast cancer after age 50 Bilateral breast cancer Breast and ovarian cancer Ovarian cancer at any age Male breast cancer at any age Relative with BRCA mutation Strong family history of breast/ovarian cancer Pancreatic cancer Ashkenaz/Eastern European Jewish DescentMedical Conditions (Adults Only)Have you had any of the following? If yes, please check, if no problems, check the no problems box.General Health Recurrent infections Recurrent fever Fatigue Night sweats Recent weight gain Recent weight loss Decreased appetite No ProblemsCommentsSkin Sores Hair loss Non-healing wound Changes in moles New lesions Burn trauma Rash Lumps/growths No problemsCommentsHead, Ears, Eyes, Nose, Throat Ear infection Nose bleeding Cataracts Sore throat New lesions Seasonal allergies Eye infections Headaches Corrective lenses Blurred vision No problemsCommentsLung Difficulty breathing Cough Sleep on more than 1 pillow Cough blood or mucus Wheezing No problemsCommentsBreast Breast lump/mass Breast pain Breast swelling Nipple discharge Nipple pain Skin changes No problemsCommentsHeart Chest pain Tightness Thumping or pounding Heart murmur Swollen arms or legs Shortness of breath Rheumatic fever High blood pressure No problemsCommentsStomach and Intestinal Special diet Heartburn Rectal bleeding Nausea Vomiting Ulcers Difficulty swallowing Indigestion Constipation Diarrhea Rectal Bleeding Blood in stool Black stools Positive hemoccult Diverticulosis Diverticulitis No problemsCommentsMale Reproductive Painful urination Frequency Impotency Prostate problems Urgency Testicular pain No problemsCommentsFemale Reproductive Painful urination Frequency Blood clots Irregular periods Urgency No problemsCommentsMuscle, Bone, and Joint Joint pain Muscle pain Back pain Neck pain Joint stiffness Joint swelling Muscle cramping No problemsCommentsNervous System Seizures Dizziness Loss of consciousness Decreased memory Fainting Problems speaking Problems moving No problemsCommentsVeins (blood vessels), lymphatic Abnormal bleeding Anemia Easy bruising Enlarged lymph nodes No problemsCommentsAllergiesAre you allergic to any medications, prescribed or over the counter? Yes NoPlease list the medication and reaction you hadInclude aspirin, Tylenol, vitamins, over the counter medications, herbal remedies, supplements etc..Are you allergic to any contacts such as latex, adhesive tape, or betadine? Yes NoPlease list the contact and reaction you hadAre you allergic to any foods? Yes NoPlease list the contact and reaction you hadFamily HistoryAre there diseases or illnesses that family members have had? Please check the boxes below for any family member who has had the problem.Anesthetic Problems Mother Father Brother Sister Grandmother (Paternal) Grandfather (Paternal) Grandmother (Maternal) Grandfather (Maternal) Children Cousins Aunt UncleCancer - Breast Mother Father Brother Sister Grandmother (Paternal) Grandfather (Paternal) Grandmother (Maternal) Grandfather (Maternal) Children Cousins Aunt UncleCancer - Colon Mother Father Brother Sister Grandmother (Paternal) Grandfather (Paternal) Grandmother (Maternal) Grandfather (Maternal) Children Cousins Aunt UncleCancer - Endometrial Mother Father Brother Sister Grandmother (Paternal) Grandfather (Paternal) Grandmother (Maternal) Grandfather (Maternal) Children Cousins Aunt UncleCancer - Ovarian Mother Father Brother Sister Grandmother (Paternal) Grandfather (Paternal) Grandmother (Maternal) Grandfather (Maternal) Children Cousins Aunt UncleCancer - Pancreatic Mother Father Brother Sister Grandmother (Paternal) Grandfather (Paternal) Grandmother (Maternal) Grandfather (Maternal) Children Cousins Aunt UncleCancer - Other Mother Father Brother Sister Grandmother (Paternal) Grandfather (Paternal) Grandmother (Maternal) Grandfather (Maternal) Children Cousins Aunt UncleDiabetes Mother Father Brother Sister Grandmother Grandfather Children Cousins Aunt UncleHeart Disease Mother Father Brother Sister Grandmother Grandfather Children Cousins Aunt UncleHigh blood pressure Mother Father Brother Sister Grandmother Grandfather Children Cousins Aunt UncleMelanoma Mother Father Brother Sister Grandmother Grandfather Children Cousins Aunt UncleMental Illness Mother Father Brother Sister Grandmother Grandfather Children Cousins Aunt UncleStroke Mother Father Brother Sister Grandmother Grandfather Children Cousins Aunt UncleIf you selected any of the boxes regarding cancer, please list the dates of the cancer diagnosesCommentsWomen's HistoryThese questions help assess your individual risk for developing breast cancer:Date or age of first menstrual periodHave you reached menopause?At what age?How old were you when you had your 1st child?Number of pregnanciesNumber of live birthsDo you do regular self breast exams? Yes NoDate of last mammogram?Have you ever had a breast biopsy? Yes NoIf yes, how many?If yes, which breast? Right LeftWhen was this performed?Where there any abnormal cells on the biopsy? Yes NoIf yes, please mark the following: Atypical Ductal Hyperplasia Breast grouped/clustered calcifications Lobular Carcinoma Insitu (LCIS)Are you taking hormone replacement therapy? Yes NoIf yes, how long?Have you taken hormone replacement therapy? Yes NoIf yes, when did you stop?Have you or any family member been tested for a BRCA mutation? Yes NoHow many of the woman’s a first-degree relative have had breast cancer? Mother Sisters DaughtersPast Medical HistoryPlease list any SURGERIES you have had and the date they were performed.Have you ever had a colonoscopy? Yes NoIf yes, please list the date and resultsHave you ever had any serious injuries? Yes NoIf yes, please list the date(s) and the type of injuriesDo you currently have any of the following medical problems? Heart disease Diabetes High blood pressure Stroke Cataracts AIDS Ulcers Epilepsy HIV Anemia Colitis leukemia Sleep apnea Depression Kidney Disease Jaundice Lung Disease Glaucoma Reflux High Cholesterol Cancer Hepatitis A Hepatitis B Hepatitis C Hepatitis (other) Pneumonia Hypothyroidism Headaches HyperthyroidismPlease list any other health problems you haveSocial HistoryWhat is your marital status? Married Single Divorced WidowedWhat is your occupation? (Or past occupation, if retired)Do you use any NICOTINE products? No Smoke E-Cig/Vape Chewing TobaccoDo you drink alcoholic drinks? Yes NoIf yes, how much and how often?Do you take any drugs for reasons that are not medical? Yes NoIf yes, please list:Medications/Over The Counter/SupplementsDo you take any medicine? (prescribed, herbal, over the counter, or health supplements) Yes NoListMedicationDosageHow oftenWhat do you take it for? Add RemoveClick the "+" icon to add additional medicationsDo you take blood thinners? Yes NoDo you take metformin? Yes NoDo you take aspirin daily? Yes NoDo you take diet pills? Yes NoDo you take vitamin E? Yes NoDo you use a C-PAP machine? Yes NoDo you take Glucophage? Yes NoDo you take St. John's Wort? Yes NoDo you take fish oil? Yes NoAre you on hormone replacement? Yes NoIf so, how long? If stopped, when?Preferred Pharmacy?Do you have any other information you want the doctor to know?
