The Comprehensive Breast Health Center

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New Patient Form

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Brigham and Women’s
Comprehensive Breast Health Center

Today's Date:_________ Age: ______ BP ____, P______, R______.

Reason for Today’s Visit:
Palpable Mass      Nipple discharge      Breast Pain

Abnormal Mammogram

Prior Breast Problems/ Biopsies:



Menstrual History
How old were you when you had your first period? _______
Last Menstrual Period_________  Age at Menopause ___________
Have you taken Birth Control Pills ______  If yes at what age did you start____ stop____.
Have you ever taken Estrogen Replacement Therapy ______ If yes for how long_______


Reproductive History
How many pregnancies have you had? __________
How many deliveries have you had?_____
Age at first delivery _____


Family Medical History:
Please list any significant family medical problems including history of breast, ovarian or other cancers

Current Medications:


Medication Allergies:


Past Medical History:
Circle past and present medical conditions

Past Surgical Procedures:


SOCIAL HISTORY:
Occupation ___________  Do you live alone?___________________________
Do you smoke cigarettes? Yes No     Packs per day ______ How long _______
If you drink alcohol, how many glasses per week___________ ( ) I do not drink alcohol.


Pain: Do you experience pain as part of your daily life? Yes No
If yes describe the location, onset, duration and characteristics (ache, burn, throb, sharp)
If yes on a scale from 1-10, 10 being the worst rate your pain _____
If yes how do you treat the pain? _______________________________________________________.


Domestic Violence:
Have you ever felt unsafe or been afraid of anyone? Yes____, No____.
Has anyone ever hurt or threatened to hurt you or someone else that you care about? Yes___, No ____.

Notes:

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I have reviewed this document with the patient.
DATE ___________________ SIGNATURE ___________________________ CLINICIAN ID___________