Patient Name: paitent_name     Today’s Date: date

Breast History

• What is your particular breast problem? breat_problem

• Does this run in female members of your family? famYes ​​ famNo

• What is your height? height  ​​​​ Weight? weight

• What bra size do you wear? bra_size Padded or unpadded? ​​ paddedPadded paddedUnpadded

• What is your desired breast size? desired_bra_size I don’t know desired_bra_size_idk

• How many children do you have? num_children Ages? children_ages

• Did your breasts change with pregnancy? ​​ change_pregYes  ​​ change_pregNo

• Did you breastfeed? breast_feedYes breast_feedNo ​​ If no, was it by choice? breast_feed_by_choiceYes ​​ breast_feed_by_choiceNo

• History of breast disease or tumors? tumor_historyYes. tumor_historyNo

• Have you ever had a mammogram? ​​ mammogram Yes ​​ mammogram No

  • If yes, where and when? mammogram_when_where

• Have you ever had another breast surgery (reduction, enlargement, or lift)? ​​ prev_surgYes prev_surgNo

  • If yes, list doctor and date: prev_surg_doc_date

• Have you ever experience any of the following breast problems?

breast_probsNipple Discharge
breast_probsBreast Lumps (or breast cysts)
breast_probsBreast Trauma
breast_probsBreast Infections (mastitis)
breast_probsInverted Nipples
breast_probsBreast Pain or Swelling

• Are you currently taking birth control pills or receiving estrogen shots? ​​ bcYes bcNo

• If you were treated for breast cancer, did you receive chemotherapy or radiation? chemoYes chemoNo

Vaginal History
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• Do you leak urine when you laugh, cough, sneeze, or workout? urineYes urineNo

• Do you wear pantyliners daily as protection from leakage? pantylinersYes pantylinersNo

• Do tampons slip or not feel snug? temp_slipYes temp_slipNo