Medical Forms

Mammogram Screening Forms

April 2, 2019

Breast cancer, as is well known, is the most common type of cancer in females and is responsible for the highest number of deaths in females every year.

Breast cancer spreads very rapidly because of its extensive blood supply and a rich network of lymphatics. This is the very reason why a cancer of one breast spreads so quickly to another that it becomes necessary to intervene before it invades the other side of the body.

Just like that, and because of the same reason, breast cancer metastasizes to other organs of the body more rapidly than cancers of other organs.

So this makes it necessary to diagnose the disease at the very initial stages because, if diagnosed in time, breast cancer is 100 percent treatable.

Simple ways to screen for breast cancer

  1. Breast self-examination on a monthly basis
  2. If you find any signs, undergoing a simple mammogram is one of the most important and effective ways to screen for breast carcinoma.

What is a mammogram???

A mammogram, or mammography, is basically an X-ray of the breast in which low-intensity X-rays are used to examine the breast tissue. It is also called a mammogram.

Ideally, a mammogram is to be done every two years after the female reaches 50 years. But, if there is a strong family history of breast cancer, it is recommended that one undergo screening mammography after even 30 years of age.

How is a mammogram form filled out?

A mammogram form has to be filled out to get information about the patient and know any risk factors present in the lady. For example, we all know that X-rays cannot be done in a pregnant lady so we have to know first if she is pregnant at the time of mammography.

Similarly, her past medical and surgical history, and especially her family history of any kind of malignancy, are inquired about.

  1. Starting with the basic introduction of the patient, a mammogram form is filled out. The name of the patient, her age, and her date of birth are also asked, along with her contact number and email address.
  2. We also want to know if her Medicaid is active or if any other health insurance is active or not, for later purposes in case she is found positive for breast cancer.
  3. Now we want to know the reason for her visit. Is it a regular annual checkup, or did she find something suspicious in her self-examination?
  4. If she has had any previous mammograms, the report is required for further reference.
  5. Next, we ask and fill out if the lady is currently pregnant or not, or if she is taking any birth control pills or hormonal replacement therapy for any reason. Hormonal replacement therapy has a very known effect, and we want to know the drug history of this patient otherwise.
  6. In the medical history section, we are mainly interested in the family history of cancer. Any history of breast cancer in the father’s and especially the mother’s family is important to know as it has a strong genetic association.
  7. In the end, we inquired about her history of cancer or if she had undergone any procedure for this in the past.
Mammogram Screening Form

Form File Size: 45 KB

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