One in every eight women will be diagnosed with breast cancer during her lifetime. Annual mammograms are recommended for women over the age of 40, as well as for younger women who have specific breast cancer risk factors.

Breast cancer warning signs and symptoms can vary greatly.

​​Make an appointment with your doctor if you notice any changes in your breast, nipple, or underarm.

Patient Information:

Surgical History:

Patient History:

Are you a smoker?

 No    Yes 

Do you drink alcohol?

 No    Yes 

Have you had the following?

Chest Pain:

 No   Yes 

Cancer:

 No    Yes 

Hepatitis C:

 No    Yes 

Problems with Scarring:

 No    Yes 

Heart Murmur:

 No    Yes 

Bleeding Disorders:

 No    Yes 

Kidney Problems:

 No    Yes 

Emotional Problems:

 No    Yes 

Hight Blood Pressure:

 No    Yes 

Breast Disease:

 No    Yes 

Asthma:

 No    Yes 

HIV:

 No    Yes 

Anemia Diabetes:

 No    Yes 

Thyroid Disorder:

 No    Yes 

Seizures:

 No    Yes 

Dryness of Eyes:

 No    Yes