DATA BASE AND HISTORY

Name of Client: DN (BC Cancer ID # 10-45678) Sex: FEMALE Age: 48 Year old Religion: N/A
Civil Status: N/A Income: N/A Nationality: N/A
Pulse Rate: N/A Resp. Rate: N/A BP: N/A Height: 165.1 cm Weight: 59.1 kg

Chief Complaint and History of Present Illness:

Diagnosed with breast cancer, pathology report indicates: invasive lobular carcinoma, high risk,
grade 3, tumour size 2.5 cm, no lymph vascular invasion (0/11 lymph nodes involved), estrogen and
progesterone receptor positive (3+/3+), HER2 negative. Patient has had mastectomy and is
scheduled for chemotherapy treatment.

Type of Previous Illness/ Date Type of Previous Illness Date

Pregnancy/Delivery Pregnancy/Delivery

N/A N/A N/A N/A

N/A N/A N/A N/A

N/A N/A N/A N/A

Has received blood in the past: ___ Yes ___ No. If yes, list dates _____Reactions: ___Yes ___ No

Medication Name Dose/ Time of Medication Dose/ Time of Last

Last Name
Frequency Frequency Dose
Dose

Epirubicin 160 mg IV push

Fluorouracil 800 mg IV push

cyclophosphamide 800 mg IV in 100 to

250 ml NS over 20
to 60 minutes

Were you admitted? N/A Yes _________No If Yes, where?_____________________

Attending Physician: N/A