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No SI
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Current SI
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Accompanied by:
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Weight, Height, BMI
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Diet
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Regular Exercises
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Nursed
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Time Nursing (months)
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Nulliparous
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Weight Lost?
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since when
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Medical Weight loss.
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Currently using or not?
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Comments
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Surgical / Oncological History
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Referring Surgeon
• • •
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Location
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Other Surgeon
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No previous symptoms
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Fibrocystic Dis
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Found on Routine Mammo
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Palpable mass
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Mastodynia
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Abnormal Nipple Discharge
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Previous Breast CA
• • •
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Previous Breast disease
|
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Breast CA Hx?
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Relatives
• • •
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Age of Relative's Diagnoses
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Comments
|
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Genetic Test Status
• • •
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Comments
|
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No previous Breast Surgeries
|
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Previous Breast Surgeries
• • •
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Previous surgery (Detailed)
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Comments
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Biopsies
• • •
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Date
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Diagnoses
• • •
|
Tumor Site
• • •
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Size of Tumor (cm)
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Comments
|
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Pathology Staging
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Estrogen
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Progesterone
|
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Her2
|
Triple Negative BC
|
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Ki-67
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Metastasis
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Stage
|
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Mammaprint
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Onco-Type
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Fish Receptor
|
Oncogene
|
|
Brought Neg studies?
• • •
|
Date Most recent Mammogram
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Previous Breast Studies
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Comments
|
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Oncologist
• • •
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Other Oncologist
|
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Oral Therapy
• • •
|
|
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Chemotherapy
|
Last Chemo (Date)
|
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Current Chemotherapy
• • •
|
Current Therapy
|
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Comments
|
Comments
|
|
RadioOncologist Dr.
|
Comments
|
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Got Radiotherapy
|
Last Radio
|
|
Need Radiotherapy?
|
Comments
|
|
Breast Examination
|
|
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Bra Size
|
Bra Cup
|
|
Skin Envelope
• • •
|
Palpation
• • •
|
|
Ptosis:
• • •
|
Symmetry
|
|
Shape of Breast
• • •
|
Lateral Rolls
|
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Chest Wall
• • •
|
Breast Measurements
|
|
Breast Capsule
• • •
|
Comments
|
|
NAC sensation
|
Palpable Masses
• • •
|
|
Breast Defect
|
Location
|
|
Amastia
• • •
|
Partial Mastectomy
• • •
|
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Breast Scars none
|
Breast Scars
• • •
|
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Previous Abdominal Surgery
• • •
|
Abd. Surg.
|
|
Clinical pictures taken?
|
Patient Photo
|
|
Breast Measurements
|
Diagrams
|
|
Breast Diagram
|
Breast Diagrams AP/Lat
|
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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
|
|
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Rec Procedures
• • •
|
and Additional Proc
|
|
Rec Proc Detailed
|
Comments
|
|
No Surgery recommended
|
|
|
Delayed Rec with Markings
|
Delayed Reconstruction Rec
|
|
Breast Reconstruction
|
|
|
Type of Reconstruction
• • •
|
Comments
|
|
Implant Follow Ups
|
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
|
|
Implant Follow Ups
|
|
|
Implants Ordered
|
Comments
|
|
BIA-ALCL Discussion?
|
|
|
Mastopexy
|
|
|
Laterality
|
Incision
|
|
Mastopexy implant?
|
Desired Cup size
|
|
Silicone gel?
|
Implants Ordered
|
|
Implant Follow Ups
|
Comments
|
|
BIA-ALCL Discussion?
|
|
|
Breast Reduction
|
|
|
Laterality
|
Incision
|
|
Right Breast Resection
|
Left Breast Resection
|
|
Desired Cup size
|
Comments
|
|
Axillary Liposuction Recommended
|
|
|
Good Candidate?
|
|
|
Follow up in?
|
Weight to loose?
|
|
Comments
|
Comments
|
|
Get Implant info?
|
Radiology
• • •
|
|
Hospital based?
|
Preop Follow up
|
|
Hospital Stay?
|
|
|
Drains
|
|
|
Recovery period
|
Will Discuss with Consultant
|
