Breast Cancer Screening Form v 0.01

Demographics

AMRS ID Number:

Family Name:

Given Name:

Middle Name:

Gender:

Date Of Birth:

Encounter Details

Name of Dispensary:*

Encounter Date:*

How did you learn about this service (check all that apply)?*

Radio

Newspaper

Word of mouth

AMPATH

Moi teaching and referral hospital

Non-MTRH consultant

Patient referral

Other

Specify:*

Past Medical History

Prior history of breast cancer?*

Previous history of radiation to the chest?*

Do you presently, or have you in the past smoked cigarettes?*

Do you presently, or have you in the past consumed alcohol?*

Have you ever had a breast biopsy?*

Have you ever had breast surgery?*

Gynecologic History

Age of menarche (first period)?*

Menarche is the first menstrual cycle, or first menstrual bleeding, in female humans.

Number of previous pregnancies?*

If client has never been pregnant, enter '0'.

Age at first pregnancy?*

What is the age of first pregnancy?

Number of previous deliveries?*

The number of children a woman has delivered?

Did you breastfeed your children?

How are your menstrual periods?*

Screener to select one best option.

First day of your last period (LMP)?*

Do you know why you are not having your period?

Family Breast Cancer History

Any history of breast cancer in the family?*

Relative(s) in the family with history of breast cancer?*

Sibling(s)

Mother

Maternal aunt(s)

Paternal aunt(s)

Other

Number of family members with history of breast cancer?*

Symptoms related to breast?*

No complaints

Breast pain

Breast mass

Nipple discharge

Breast skin changes

Breast skin inflammation / abscess

Breast pain duration?

Breast mass duration?

Nipple discharge duration?

Breast sking changes duration?

Breast skin inflammation / abscess duration?

Physical Examination

Systolic blood pressure (mmHg):*

Diastolic blood pressure (mmHg):*

Pulse rate (per minute):*

Respiratory rate:*

Temperature (centigrade):*

Weight (kg):*

Height (cm):*

Body surface area (m^2)

Breast Exam Findings

Breast exam findings?*

Which breast has finding?:*

Specific location?*

Lymph node exam findings?*

Submandibular

Supraclavicular

Cervical

Axillary

Generalized lympadenopathy

Normal

Not done

Skin Exams Findings

Skin exam findings?*

Body part with finding?:*

Specific location?*

Mass measurement in cm, first direction:

Mass measurement in cm, second direction:

Select all referrals made during this visit:*

Pathology

Surgery

Radiology

Oncology

MTRH

Other

None

Specify:*

Reasons for referral*

Fine needle aspiration (FNA)

Core needle biopsy

Excisional or surgical biopsy

Surgery

Wound debridement

Ultrasound

Other

Specify:*

Provider Name:

Enter provider's system-id:*

Return visit date: