Follow the steps to successfully fill out the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the document editor.
2. Begin with the section for patient information. Fill in your full name, age, date of birth, and sex. Ensure that you provide an accurate email address along with your complete address, including city, state, and zip code.
3. Proceed to provide your contact numbers, including both home and work telephone numbers. This ensures that the healthcare provider can reach you if needed.
4. In the ethnic origin section, indicate whether this is your first mammogram by selecting 'Yes' or 'No.' If you have previously had a mammogram, record when and where it was conducted.
5. Answer the questions regarding breast implants and indicate the type (silicone or saline) if applicable. Provide further details regarding any previous breast surgeries or biopsies.
6. Next, address any indicated problems. Answer questions about any lumps, pain, or abnormalities, specifying the side (right or left) as necessary. Include information about any past or current diagnoses such as cancer.
7. Complete the family history section by listing any family members diagnosed with cancer and their age at diagnosis, if applicable. Indicate whether you have had a mastectomy or lumpectomy and provide dates where required.
8. Document your menstrual history, including the age when menstruation began and stopped, as well as the date of your last menstrual period. Also, indicate if you have ever been pregnant.
9. Finally, review all provided information for accuracy. Once confirmed, sign electronically to certify that the information is correct to the best of your knowledge. Include the date of your signature.
10. After completing the form, you can save changes, download, print, or share it as needed.

Ensure your health is a priority by completing your Mammography Intake Form online today.