|
No SI
|
Current SI
|
|
Weight, Height, BMI
|
Accompanied by:
|
|
Regular Exercises
|
Diet
|
|
Nursed
|
Time Nursing (months)
|
|
Weight Lost?
|
since when
|
|
Comments
|
|
|
Surgical / Oncological History
|
|
|
Breast CA Hx?
|
Relatives
• • •
|
|
Age of Relative's Diagnoses
|
Comments
|
|
Genetic Test Status
• • •
|
Comments
|
|
No previous symptoms
|
Found on Routine Mammo
|
|
Mastodynia
|
Abnormal Nipple Discharge
|
|
Palpable mass
|
Fibrocystic Dis
|
|
No previous Breast Surgeries
|
|
|
Previous Breast Surgeries
• • •
|
Previous surgery (Detailed)
|
|
Previous Breast CA
• • •
|
Previous Breast disease
|
|
Referring Surgeon
• • •
|
Other Surgeon
|
|
Biopsies
• • •
|
Date
|
|
Diagnoses
• • •
|
Tumor Site
• • •
|
|
Size of Tumor (cm)
|
Comments
|
|
Pathology Staging
|
|
|
Tumor size
|
Nodes
|
|
Metastasis
|
Stage
|
|
Estrogen
|
Progesterone
|
|
Her2
|
Onco-Type
|
|
Mammaprint
|
Ki-67
|
|
Fish Receptor
|
Oncogene
|
|
Brought Neg studies?
• • •
|
Date Most recent Mammogram
|
|
Previous Breast Studies
|
Comments
|
|
Chemotherapy
|
Last Chemo (Date)
|
|
Oncologist
• • •
|
Other Oncologist
|
|
Current Chemotherapy
• • •
|
Current Therapy
|
|
|
Comments
|
|
Got Radiotherapy
|
Last Radio
|
|
Need Radiotherapy?
|
|
|
RadioOncologist Dr.
|
Comments
|
|
Breast Examination
|
|
|
Bra Size
|
Bra Cup
|
|
Skin Envelope
• • •
|
Palpation
• • •
|
|
Ptosis:
• • •
|
Symmetry
|
|
Shape of Breast
• • •
|
Lateral Rolls
|
|
Chest Wall
• • •
|
|
|
Breast Capsule
• • •
|
Comments
|
|
NAC sensation
|
Palpable Masses
• • •
|
|
Breast Defect
|
Location
|
|
Amastia
• • •
|
Partial Mastectomy
• • •
|
|
Breast Scars none
|
Breast Scars
• • •
|
|
Previous Abdominal Surgery
• • •
|
Abd. Surg.
|
|
Breast Diagram
|
Breast Diagrams AP/Lat
|
|
Diagrams
|
|
|
Clincal pictures taken?
|
|
|
Measurements
|
Comments
|
|
Breast width Left in cm
|
Breast width Right in cm
|
|
Sternum → Nipple Left in cm
|
Sternum → Nipple Right in cm
|
|
Nipple → IMF Left in cm.
|
Nipple → IMF Right in cm
|
|
Sternum → Areolar diameter Left
|
Sternum → Areolar diameter Right in cm
|
|
Left Areola Measurement in mm.
|
Right Areola Measurement
|
|
Breast Diag Measurements
|
|
|
Defect
• • •
|
|
|
Treatment Plan
|
|
|
Rec Procedures
• • •
|
and Additional Proc
|
|
Rec Proc Detailed
|
Comments
|
|
No Surgery recommended
|
|
|
Breast Reconstruction
|
|
|
Type of Reconstruction
• • •
|
Comments
|
|
Expander Type
|
Expander size
|
|
Refer to Implant Catalog
|
|
|
ADM Brand
• • •
|
ADM size
|
|
BIA-ALCL Discussion?
|
Comments
|
|
Breast Augmentation
|
|
|
Laterality
|
Incision
|
|
Silicone gel?
|
Refer to Implant Catalog
|
|
Desired Breast Cup
|
Comments
|
|
Implants Ordered
|
Comments
|
|
BIA-ALCL Discussion?
|
|
|
Mastopexy
|
|
|
Laterality
|
Incision
|
|
Mastopexy implant?
|
Desired Cup size
|
|
Silicone gel?
|
Implants Ordered
|
|
Comments
|
BIA-ALCL Discussion?
|
|
Breast Reduction
|
|
|
Laterality
|
Incision
|
|
Right Breast Resection
|
Left Breast Resection
|
|
Axillary Liposuction Recommended
|
Desired Cup size
|
|
Good Candidate?
|
|
|
Follow up in?
|
Weight to loose?
|
|
Comments
|
Comments
|
|
Get Implant info?
|
Radiology
• • •
|
|
Hospital based?
|
Preop Follow up
|
|
Drains
|
Hospital Stay?
|
|
Recovery period
|
Will Discuss with Consultant
|
