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History (upper back/neck pain)
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History Comments
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Referring Physician
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Smoking
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Bra Size
• • •
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Bra Size Comments
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Breast Surgery
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Breast Surgery List
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Breast Surgery Comments
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Gravida
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Para
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Breast CA Family History (immediate)
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Breast CA Family History Comments
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Mammography (available)
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Mammography Results
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Breast Imaging Comments
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Physical Exam
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Right Breast
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Ptosis
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Ptosis Grade
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Scar
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Scar Location/Type
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Mass
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Mass Location
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Shoulder Grooving
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Intertrigo
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SN-N Distance (cm)
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N-IMF Distance (cm)
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Comments
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Left Breast
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Ptosis
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Ptosis Grade
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Scar
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Scar Location/Type
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Mass
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Mass Location
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Shoulder Grooving
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Intertrigo
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SN-N Distance (cm)
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N-IMF Distance (cm)
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Comments
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Pictures
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Assessment
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Plan
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Consent
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Breast Diagram
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