|
Patient's Request
|
Patient's Request Comments
|
|
Smoking
|
|
|
Bra Size
• • •
|
Bra Size Comments
|
|
Breast Surgery
|
Breast Surgery List
|
|
Breast Surgery Comments
|
|
|
Gravida
|
Para
|
|
Breast CA Family History (immediate)
|
Breast CA Family History Comments
|
|
Mammography (available)
|
Mammography Results
|
|
Breast Imaging Comments
|
|
|
Physical Exam
|
|
|
Right Breast
|
|
|
Ptosis
|
Ptosis Grade
|
|
Tuberous Deformity
|
Tuberous Grade
|
|
Capsular Contracture (if implant)
|
Capsular Contracture Grade
|
|
Scar
|
Scar Location/Type
|
|
Mass
|
Mass Location
|
|
SN-N Distance (cm)
|
N-IMF Distance (cm)
|
|
Diameter (cm)
|
Comments
|
|
Left Breast
|
|
|
Ptosis
|
Ptosis Grade
|
|
Tuberous Deformity
|
Tuberous Grade
|
|
Capsular Contracture (if implant)
|
Capsular Contracture Grade
|
|
Scar
|
Scar Type/Location
|
|
Mass
|
Mass Location
|
|
SN-N Distance (cm)
|
N-IMF Distance (cm)
|
|
Diameter (cm)
|
Comments
|
|
|
|
|
Pictures
|
|
|
Assessment
|
Plan
|
|
Consent
|
Breast Diagram
|
