|
Mastectomy Side (if immediate)
|
Breast Surgeon (if immediate)
|
|
Mastectomy Side (if delayed)
|
Mastectomy Date (if delayed)
|
|
Mastectomy Side (if prophylactic)
|
Breast Surgeon (if prophylactic)
|
|
History Comments
|
|
|
Smoking
|
|
|
Diabetes
|
Insulin
|
|
Breast Surgery
|
Breast Surgery List
|
|
Radiation
|
Radiation Location
|
|
Radiation Date (last dose)
|
|
|
Chemotherapy
|
Chemotherapy Date (last dose)
|
|
Pathology Report
|
|
|
Bra Size
• • •
|
|
|
Gravida
|
Para
|
|
Abdominal Surgery
|
Abdominal Surgery List
|
|
Physical Exam
|
|
|
Right Breast
|
|
|
Ptosis
|
Ptosis Grade
|
|
Scar
|
Scar Location or Type
|
|
Hyperpigmentation skin changes
|
Hyperpigmentation Location
|
|
Mass
|
Mass Location
|
|
Diameter (cm)
|
Comments
|
|
Left Breast
|
|
|
Ptosis
|
Ptosis Grade
|
|
Scar
|
Scar Location or Type
|
|
Hyperpigmentation Skin Changes
|
Hyperpigmentation Location
|
|
Mass
|
Mass Location
|
|
Diameter (cm)
|
Comments
|
|
Abdomen
|
|
|
Scar
|
Scar Location
|
|
Hernia
|
Hernia Location
|
|
Panniculus
|
Panniculus Degree
|
|
Comments
|
|
|
|
|
|
Pictures
|
|
|
Assessment
|
Plan
|
|
Consent
|
|
|
Breast Diagram
|
Abdomen Diagram
|
