Dear --------:

RE: FOLLOW-UP ACTION REPORT

Following an abnormal screening mammography report, the following patient was referred to you for coordination of follow-up and diagnosis. We would like to ascertain the outcome of this follow-up so that we are aware whether she is eligible for further screening visits. As well, this outcome information is critical in evaluating the effectiveness of our screening service. Thank you very much for your assistance by returning this completed form in the enclosed postage prepaid envelope when her follow-up is complete.

Please complete the following if you examined this woman around the EXAM DATE shown above:

FOLLOW-UP PROCEDURES Carried Out After EXAM DATE	Date & Place of Exam	TEST RESULT
Diagnostic Mammogram	_____________	malignant DCIS LCIS benign equivocal
Ultrasound	_____________	malignant DCIS LCIS benign equivocal
Surgical Consult	_____________	malignant DCIS LCIS benign equivocal
Fine Needle Aspiration	_____________	malignant DCIS LCIS benign equivocal
Core Biopsy	_____________	malignant DCIS LCIS benign equivocal
Open Biopsy with fine wire localization	_____________	malignant DCIS LCIS benign equivocal
Open Biopsy without fine wire localization	_____________	malignant DCIS LCIS benign equivocal
Other (please specify ________________)	_____________	malignant DCIS LCIS benign equivocal
FINAL RESULTS OF FOLLOW-UP: Malignant DCIS LCIS Benign

Any copies of reports you can provide would be greatly appreciated.
Please provide any comments you may have on the back of this form.
If there are further investigations, we would appreciate having you inform us.

RETURN IN THE ENCLOSED POSTAGE PREPAID ENVELOPE

Appendix A - Table of Contents