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Micromastia History
• • •
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Patient's Request
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Patient's Request Comments
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Smoking
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Prior Breast Surgery
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Prior Breast Surgery Detail
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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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Previous Mammogram?
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Mammography Results
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Mammogram or Sonogram Done Place & Date
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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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Tuberous Deformity
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Capsular Contracture (if implant)
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Capsular Contracture Grade
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Past Breast Surgery Scar
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Past Breast Surgery Scar
• • •
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Mass
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Mass Location
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Diameter (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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Tuberous Deformity
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Capsular Contracture (if implant)
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Capsular Contracture Grade
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Past Breast Surgery Scar
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Past Breast Surgery Scar
• • •
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Mass
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Mass Location
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Diameter (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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