Last name First name Middle name Registry No.

Outreach
Sex: [ ] Male [ ] Female Age: Birthday: Civil Status: [ ] Single [ ] Widow
[ ] Married [ ]

Residence Address: ___________________________________________________________________

Tel. No. / Pager No. / Cellphone No.: _______________________________________________________
Business Address: ___________________________________________________________________
Tel. No. / Pager No. / Cellphone No.: _______________________________________________________
Date of Initial Evaluation: _______________________ Referred by: _______________________________
[ ] Lecture [ ] BSE Class [ ] Consultation [ ] FNAB [ ] Open Biopsy [ ] Others: _________

CLINICAL HISTORY
Chief Complaint: _______________________________________________________________________
Age of Menarche: ______ years old Date of Last Menstrual Period: ___________________
Menopause: ______ years old
Obstetric History:
[ ] Nulliparous
Gravida ________ Paragravida ________ Age of First Full Term Pregnancy: ________________
Breast Feeding:
[ ] No [ ] Yes Cumulative No. of Years: _______________________
History of Intake of Contraception Pills:
[ ] No [ ] Yes Cumulative No. of Years: _______________________
Personal Medical History: [ ] Nothing Significant
[ ] Breast CA ____________________________________________________________________
[ ] Other Cancer _________________________________________________________________
[ ] Other Conditions _______________________________________________________________
Hormonal Replacement Therapy
[ ] No [ ] Yes Date Started: _____________ Date Stopped: _____________
Family History: [ ] Nothing Significant
[ ] Breast CA (relationship): _________________________________________________________
[ ] Cervical / Ovarian / Uterine CA / Colorectal / Thyroid / Colon

PHYSICAL EXAM Right Left

PLEASE INDICATE

 Number of Masses
 Size (Centimeters)
 Consistency (Hard, Soft, Firm)
 Tenderness (+) (-)
 Fixation (Skin, Chest Wall, None)
 Skin Changes
(Erythema, Ulceration, Bleeding,
“Peau d’ orange”, Dimpling,
Nipple Retraction, None)
Breast Pain: [ ] Absent [ ] Present
Character: [ ] Non-cynical [ ] Cynical
Pain Score: 1 2 3 4 5 6 7 8 9 10

Other Non-Breast Related Findings: _______________________________________________________

____________________________________________________________________________________
CLINICAL IMPRESSION _____________________________________________________________
____________________________________________________________________________________

PLAN _______________________________________________________________________________
PLAN DATE REQUESTED PLAN DATE REQUESTED
[ ] Mammogram ____________________ [ ] Open Biopsy ____________________
[ ] Ultrasound ____________________ [ ] Follow up Consult ____________________
[ ] FNAB ____________________ [ ] Others ____________________
[ ] CNB ____________________
MAMMOGRAM
[ ] Initial (Baseline) [ ] Follow up
Date: ________________________ Date: ________________________
Hospital:________________________ Hospital: ________________________
Result: ________________________ Result: ________________________
ULTRASOUND FNAB
[ ] Done [ ] Done
Date: ________________________ Date: _______________________
Hospital/Lab: ____________________ Hospital/Lab:_____________________
Result: ________________________ Result: _________________________
CNB OPEN BIOPSY
[ ] Done [ ] Done
Date: ________________________ Date: ________________________
Hospital/Lab: ____________________ Hospital/Lab: ____________________
Result: ________________________ Result: ________________________

SUGGESTED DISPOSITION
[ ] If benign: (Follow up after 6 months) To come back __________________ for Clinical Breast Exam
(Date)

[ ] If still suspicious for malignancy: (Follow up every month until resolved) To come back ____________
(Date)
[ ] If malignant: (Work-up and Treatment)
WORK-UP RESULTS
[ ] Chest X-ray _______________________________________________________
[ ] SGPT _______________________________________________________
[ ] ALKALINE PHOSPHATASE _______________________________________________________
[ ] LIVER ULTRASOUND _______________________________________________________
[ ] ERA / PRA _______________________________________________________
[ ] BONE SCAN _______________________________________________________
[ ] OTHERS _______________________________________________________
[ ] CLINICAL [ ] PATHOLOGIC [ ] RECURRENT T ____ N ____ M ____ STAGE ____
Treatment Plan: __________________________________________________________________
__________________________________________________________________
__________________________________________________________________

ACCOMPLISHED BY: ____________________________

(Print Name)