Age *

Sex *


Main Complaint *















Do you feel any lump ?



Is there any dimpling, puckering or ulcer on the skin ? *


Do you have a past medical history of breast cancer ? *


Is there any blood in discharge ?


Is it staining your clothes ?


Does it happen more than twice a week ?


Has it been more than 2 months ?


Have you tried a conservative management for pain relief ?


Is it tender or rapidly growing in size ?


Do you have any first degree relative (parents, children, siblings) with breast cancer ?


Do you have any second degree relative (uncles, aunts, grandparents, cousins, nephews, nieces, half-siblings) with breast cancer ?


Anyone in your family who was diagnosed with breast cancer under the age of 50 ?


Any male family member with breast cancer ?


Is there anyone in the family with BRCA gene positive for breast cancer ?


Name

Date Of Birth

Do you have any first degree relative (parents, children, siblings) with breast cancer?


Do you have any first degree relative (parents, children, siblings) with ovary cancer?


Do you have a past medical history of breast cancer?


Previous diagnosis of gynaecomastia?


Did you have previous breast surgery?


What type of previous surgery you had on the same side of the new symptom of breast ?

Which side of breast you had surgery on?

Did you take any medication or stroid pills that can supress your imune system ?


Do you have a history of diabetes ?


Have you been diagnosed with obesity or consider yourselt obese (BMI > 30) ?


Do you smoke ?


Other past medical history

Which regular medication do you take ?

Did you have any allergies

Name

Date Of Birth

Number of children

What age did you start your periods (age of menarche)?

Age at menopause ?

How long in months you have breastfed for ?

Do you have any first degree relative (parents, children, siblings) with breast cancer?


Do you have any first degree relative (parents, children, siblings) with ovary cancer?


Do you have a past medical history of breast cancer?


Do you have a past medical history of non-cancer breast condition?


Did you have past medical history of ovary cancer?


Did you have previous breast surgery?


What type of previous surgery you had on the same side of the new symptom of breast ?

Which side of breast you had surgery on?

For how many years in total have you taken hormonal contraception (pills implant etc) or hotmone replacement therapy ?


Do you take any medication or steriod pills that can supress your imune system ?


Do you have a history of diabetes ?


Have you been diagnosed with obesity or consider yourselt obese (BMI > 30) ?


Do you smoke ?


Other past medical history

Which regular medication do you take ?

Did you have any allergies