Breast Patient Online Form

*Patient Name:
*Date of Birth:
*Social Security #:
Primary Care Physician:
*Referring Physicians:
Surgeon or other physicians you would like notified of your progress:
*Home Address:
*Home Phone #:
Work #:
Cell #:
E-Mail Address:

Check In Information

*Location:	Burleson Cleburne Denton Fort Worth - Central Campus Fort Worth - Southwest Granbury Mineral Wells Stephenville Weatherford Other
Physician:	Matthew L. Cavey, M.D. Gregory Friess, D.O. Shanthi Ganesa, M.D. Nathan Kim, M.D., Ph.D. Peter LaNasa, M.D. H. Lance Mandell, M.D. Shadan Mansoor, M.D. Ann-Margaret Ochs, D.O. Ray D. Page, D.O., PhD Vinaya Potluri, M.D. Bibas Reddy, D.O. Michael Ross, M.D. Mary Ann Skiba, D.O. DeEtte Vasques, D.O. Henry Q. Xiong, M.D., PhD Robyn R. Young, M.D.

Patient Information

Employer:
Work Phone:
Retired:	Yes No
If yes, where from?:

Spouse/Policyholder Information

Name of Spouse:
Date of Birth:
Social Security #:
Retired?:	Yes No
If yes, where from?:
Employer:
Work Phone #:

Primary Insurance Information

Policy Type:	Group Individual
*Insurance Name:
*ID #:
Group #:
*Insurance Telephone #:
Who's employer is insurance through?:	Patient Spouse

Secondary Insurance Information

Policy Type:	Group Individual
Insurance Name:
ID #:
Group #:
Insurance Telephone #:
Who's employer is insurance through?:	Patient Spouse

Emergency Contact

*Name:
* Relationship:
Address:
*Telephone:

To whom may we release information and records regarding your care

Name:
Relationship:
Name:
Relationship:

AS A COURTESY TO OUR PATIENTS, WE WILL FILE WITH YOUR INSURANCE. I AUTHORIZE THE RELEASE OF MEDICAL INFORMATION NECESSARY TO PROCESS THE CLAIM. I HEREBY AUTHORIZE PAYMENTS DIRECTLY TO UNDERSIGNED PHYSICIAN(S) FOR THE SURGICAL AND/OR MEDICAL BENEFITS, IF ANY, OTHERWISE PAYABLE O FOR HIS/HER SERVICE. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR THE CHARGES NOT COVERED BY THIS AUTHORIZATION.

*Date:
*Signature of Insured:

Do you presently have or ever had any of the following?

				Year Diagnosed
Diabetes:	Yes	No
High Blood Pressure:	Yes	No
Heart Disease:	Yes	No
High Cholesterol:	Yes	No
Chest Pain:	Yes	No
Emphysema:	Yes	No
Asthma:	Yes	No
Colon Polyps:	Yes	No
Rectal Bleeding:	Yes	No
Strokes / TIA’s:	Yes	No
Brain Injury:	Yes	No
Seizures:	Yes	No
Dizziness:	Yes	No
Glaucoma:	Yes	No
Thyroid Problems:	Yes	No
Hepatitis:	Yes	No
Ulcers:	Yes	No
Depression:	Yes	No
Cataracts:	Yes	No

Other:
Are You in Pain for any Reason?:
Pain Medicine:

Please Rate Your Pain on a Scale of 0-10 (0 = No Pain and 10 = Worse Pain):
Do You Have Any Difficulty Reading or Hearing Verbal Instructions in English?:

Breast Cancer Screening History

Date of Last Mammogram:
Where Was it Done?:

Are There Any Other Mammograms on File at Another Location?:

Yes

No

If So, Where?:

Breast Surgical History

Type of Procedure				Date
Biopsy / Aspiration(s):	Left	Right
Cyst Aspiration(s):	Left	Right
Lumpectomy/Cancer:	Left	Right
Mastectomy:	Left	Right
Implants:	Left	Right				What Type?:
Breast Reduction:	Left	Right
Reconstruction:	Left	Right				What Type?:

Other Surgical History

Please list any other surgical procedures you have had performed and the year done.

Procedure		Year

Gynecological History

How Old Were You When You Started Having Menstrual Cycles (Periods)?:

How Many Times Pregnant?:
# of Live Births:
Your Age at First Delivery:

Did You Breast Feed?:	Yes	No		For How Long?:
Are You Still Having Periods?:	Yes	No		Date of Last Period:
Have You Had a Hysterectomy (Removal of Uterus)?:	Yes	No		If So, When?:
Have Your Ovaries Been Removed?:	Yes	No		If So, When?:
Have You Had a Pelvic Exam or Ultrasound Recently?:	Yes	No		If So, When?:
Are You Currently Taking Hormones or Birth Control Pills?:	Yes	No		Name:
Did You Take Birth Control Pills in the Past?:	Yes	No		Name:

If Yes, When Did You Stop Taking Them?:
If Yes, How Long Did Take Them?:

Have You Taken Hormones in the Past?:

Yes

No

Name:

If Yes, When Did You Stop Taking Them?:
How Long Did You Take Them?:

Personal Medical History

Drug Allergies?:
Other Allergies?:
What is Your Height?:
Weight?:

Do You Exercise Routinely?:	Yes	No
Do You Smoke?:	Yes	No

How Much?:

Have You Quit Smoking?:

Yes

No

How Long Did You Smoke For?:
How Many Packs a Day?:

Do You Drink Alcohol?:

Yes

No

How Much?:
How Many Days a Week?:

Have You Worked With or Been Exposed to any Chemicals?:

What Hobbies or Pastimes Do You Have?:

Are You Currently Employed?:

Yes

No

If Yes, What Kind of Work Do You Do?:

Are You on Disability?:

Yes

No

Please list your current medications.

Drug/Herbal Name		Dosage

Family History of Cancer

Is Your Mother Alive?:

Yes

No

If Not, What Age Was She When She Died?:
What Did She Die Of?:

Is Your Father Alive?:

Yes

No

If Not, What Age Was He When He Died?:
What Did He Die Of?:

How Many Sisters Do you Have?:
How Many Brothers Do you Have?:

Have You Been Diagnosed With Any Other Type of Cancer? If Yes, What Type and at What Age Were You Diagnosed?:

Have You Had Genetic Testing Done for Hereditary Cancer?:

Yes

No

Results?:

Please note if any other family member had cancer and what type: (Breast, Ovarian, Colon, Prostate, Uterine, Cervical, etc) If yes to any to any please list the age they were when diagnosed. This is very important information.

Mother:
M. Grandmother:
M. Grandfather:
Father:
P. Grandmother:
P. Grandfather:
M. Aunts:
M. Uncles:
P. Aunts:
P. Uncles:
Sister:
Sister:
Brother:
Brother:

Please use the space below to list any other cancer history in your family.