|
Breast Pain Chief Complaint:
• • •
|
|
|
Characteristic of Breast Pain
• • •
|
Duration of Pain
• • •
|
|
Additional pt specific info
|
|
|
|
|
|
Breast Mass Chief Complaint
• • •
|
|
|
Details of Breast Mass
• • •
|
Duration of mass
• • •
|
|
Size/Shape
• • •
|
Size/Shape - Other
|
|
Additional pt specific info
|
|
|
|
|
|
Nipple Discharge Chief Complaint
• • •
|
Duration
• • •
|
|
Spontaneous
• • •
|
Color
• • •
|
|
Duct
• • •
|
Other
|
|
|
|
|
Imaging Chief complaint:
• • •
|
|
|
Imaging complaint
• • •
|
Nature of Abnormality
• • •
|
|
Misc.
• • •
|
Additional imaging notes:
|
|
Breast Trauma
|
Radiologist Recommendation:
• • •
|
|
Clinical notes:
|
|
|
|
|
|
High risk:
|
Reasons for high risk:
• • •
|
|
Biopsy Type
• • •
|
Date of biopsy:
|
|
Most recent imaging:
• • •
|
Date of most recent imaging:
|
|
Future imaging needed:
• • •
|
Date future imaging needed
• • •
|
|
additional info:
|
|
|
|
|
|
Lactation Problem
|
Child
|
|
Baby's Name
|
Baby's BD
|
|
Delivery Type
|
Delivery complication?
|
|
Baby's weight (lbs)
|
Baby's Feeding Frequency (hrs)
|
|
Feeding Time (min)
|
Feeding one or both breasts
|
|
Supplements
|
Supplement with
|
|
Number of Stools
|
Stool Color
|
|
Spitting
|
Months Planned Breastfeeding (months)
|
|
Breast Trauma Hx
|
Yes Breast History
|
|
Mom Work
|
Mom RTW Timing
|
|
Married
|
Mom Exercise
|
|
If Exercises What
|
Mom Alcohol
|
|
Mom Smoking
|
Mom Mood
|
|
Baby Pre Feeding Wt (gms)
|
Baby Latched
|
