APPENDIX H
BREAST HISTORY AND SCREENING MAMMOGRAPHY REPORT
HISTORY
Outside Mammogram
Yes
No
Unknown
date of most recent:__________
where: ____________________
Current Estrogen Use: (e.g., premarin, climacteron) Yes
No
Unknown
date of most recent:__________
where: ____________________
Yes
No
Breast Reduction Surgery
Yes
No
date of surgery: ____________
surgery to: Right
Left
Breast Procedures: Yes
No
date of surgery: ____________
surgery to:
Right
Left
Aspiration/needle biopsy
Biopsy - surgical
None
date of first biopsy: _______________
date of most recent biopsy: ___________
Presence of Breast Lump (patient reported)
Yes
No
NUMBER OF MAMMOGRAPHIC VIEWS TAKEN: RIGHT _______ LEFT________
Technologist Code: ________________
SCREENING MAMMOGRAPHY REPORT
This screening mammogram was read by a radiologist.
Previous films were available for comparison
1 - DY <50%
2 - DY ≥50%
Results:
No significant abnormality; repeat screening mammography in 2 years
Requires diagnostic radiology workup
Requires repeat exam due to technical reasons
Recommendation:
First compare with previous films
Coned compression magnification views
Ultrasound
COMMENTS: _______________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________
Radiologist Code: ________________
Phone GP with results
