SWEDISH BREAST IMAGING NETWORK Mammography History Worksheet Patient Sticker DATE: Is this a routine screening mammogram? ..................................................................... Yes.
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How to fill out the Information Worksheet Mammogram online
Completing the Information Worksheet Mammogram online is a crucial step in ensuring your breast imaging procedure goes smoothly. This guide will walk you through the process step-by-step, making it easy to provide the necessary information required for your mammogram.
Follow the steps to fill out your Information Worksheet Mammogram correctly.
- Click ‘Get Form’ button to access the Information Worksheet Mammogram and open it in your preferred editor.
- Begin by entering the date of your appointment in the designated field.
- Indicate whether this is a routine screening mammogram by selecting 'Yes' or 'No'.
- Respond to the question regarding pregnancy status by choosing 'Yes' or 'No'.
- If applicable, indicate if you have breast-fed in the last six months by selecting 'Yes' or 'No'.
- Provide your personal history of breast cancer, indicating 'Yes' or 'No'. If you select 'Yes', please fill in the year, side affected, type of surgery, and details about any chemotherapy, radiation, or hormonal therapy received.
- If you have had any non-cancer breast surgeries or biopsies, answer 'Yes' or 'No'. If 'Yes', detail the year, side, and type of procedure.
- Indicate whether you have a history of ovarian cancer or lymphoma by responding accordingly and providing the year and type if applicable.
- Answer the question regarding family history of breast or ovarian cancer, providing relationships, types, and ages at diagnosis if 'Yes'.
- Report any weight gain or loss of more than 10 pounds since your last mammogram.
- Fill in the information regarding your prior mammograms, including location and year.
- Certify the information provided by printing your name and signing in the designated fields.
- After reviewing all entries, save your changes, and consider downloading or printing the form for your records or to share it with the necessary parties.
Start completing your Information Worksheet Mammogram online now to ensure timely processing of your health needs.
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