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BREAST MRI QUESTIONNAIRE

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PATIENTS NAME:

Date:

DOB:

Age:

SEX:

 M F

DIAGNOSIS (Why are you having this study?)

PLEASE CHECK EACH BOX THAT APPLIES TO YOU (AND ANSWER QUESTIONS:)

When was the first day of your last menstrual period?

Do you have or have you had breast cancer?

 Yes No If yes, when?
  Which breast? Right Left
 

Did the tumor spread elsewhere in your body?

 Yes No
 

If yes, where?
 

What type of therapy did you receive?
  Surgery Yes No Chemotherapy Yes No  
  Lumpectomy Yes No Radiation therapy Yes No  
  Mastectomy Yes No Hormonal therapy Yes No  
     
Have you had breast surgery? Yes No

If so, what type?

  
  Biopsy Right Left
  Lumpectomy for benign breast mass Right Left
  Breast implants Right Left
 

If so, what type? (ie. saline or silicone)
 

When were they placed?
  Breast reduction Right Left

Have you had a breast MRI before?

 Yes No
 

If yes, where?

 Results?

When was your last mammogram?

 Results?

Have you had a breast ultrasound examination?

 Yes No
 

If yes, where?

 Results?

Do you feel a breast lump or mass?

 Yes No
 

If yes, for how long?
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