Breast Imaging Patient History / Pase Pasyan ak

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Breast Imaging Patient History / Pase Pasyan ak Imajri Pou Tete
Patient Name/ Non Pasyan: ______________________________________Today’s Date/ Jodiya: ______________ Date of Birth/ Dat Nesans: _______________
Phone# / Telefòn: ____________________________ Ordering Physician/ Doktè Ki Kòmande l la: ________________________________
No/Non Yes/Wi 1. Have you had a previous mammogram? Èske ou janm fè yon mamogram deja? If Yes/ Wi: When/Ki lè? _______________ Where/Ki Kote?_____________________
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2. Have you had a previous Breast MRI or Breast Ultrasound? Èske ou janm fè yon IRM pou Tete oubyen Ekografi pou Tete deja? If Yes/ Wi: When/Ki lè? ___________________ Where/Ki Kote?_____________________
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3. Are you having any NEW areas of pain in your breast(s)? Èske ou gen okenn NOUVO kote nan tete ou(yo) kap fè ou mal?
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4. Have you or your doctor recently found a NEW lump or mass in your breast(s)? Èske ou menm oswa doktè ou te fenk jwenn yon NOUVO boul ou mas nan tete ou (yo)?
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5. Are you having any NEW nipple discharge or NEW puckering of the skin or nipple? Èske ou gen okenn NOUVO dlo kap soti nan pwent tete ou oubyen èske po a oubyen pwent tete a fenk KÒMANSE ap plise?
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6. Have you had any prior breast surgery? Èske ou te fè okenn operasyon nan tete deja?
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If Yes/ Wi: When/Ki lè? _________ Aspiration/Aspirasyon:Right/Dwat Left/Goch Reduction/Rediksyon ___Implants /Enplant  Other/Lòt _______________________________
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7. Do you have a history of breast cancer? Èske ou gen konn gen kansè nan tete?
If Yes/ Wi: When/Ki lè? __________ Location/Ki Kote (please circle)/(Tanpri Antoure): Right/Dwat Left/Goch Both/Tout De
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Mastectomy/Retire Tete Lumpectomy/Retire Boul Chemotherapy/Chimyoterapi # of Treatments/Tretman _____  Radiation/Radyoterapi # of Treatments/Tretman:_____
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8. Do you have a family history of breast cancer? Èske gen moun nan fanmi ou ki gen kansè nan tete?
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If Yes/ Wi: Age/Laj _______  Mother/Manman Sister/Sè Daughter/Pitit Fi Other/Lòt_______________________________
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9. Are you taking any hormone replacements? Èske w ap ran okenn tretman pou ranplase òmòn?
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10. Is there any possibility you may be pregnant? Èske gen okenn posiblite ou ka ansent?
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11. What is the date of your last menstrual period? Ki dat dènye jou ou te gen règ ou?
Date/Dat: _______________
ALL MAMMOGRAPHY PATIENTS: Please read and initial/TOUT
MAMOGRAM:
li sa ki pi ba Lea
a epiy mete
inisyal
initial PARA PASYAN
TODAS LAS
PACIENTESTanpri
DE MAMOGRAFÍA:
coloque
sus ou
iniciales
(premye
lèt chakthat
nonmammograms
w)
a. I understand
do not detect all breast cancers and that they must be combined with periodic physical
a.exam,
______Initials
I understand
thatand
mammograms
do notanydetect
breast cancers and that they must be combined with
monthly breast
self-exam,
comparison with
priorall
mammograms.
periodic
physicalEntiendo
exam, monthly
self-exam,
and comparison
anydeprior
mammograms.
______Iniciales
que lasbreast
mamografías
no detectan
todos loswith
tipos
cáncer
de seno y que se deben combinar con
______Inisyal
Mwen
konprann
mamogram
yo
pa
detekte
tout
kansè
ki
nan
tete
epi
yap
oblije melanje
ak egzamen fizik
examines físicos periódicos, autoexámenes de seno mensuales y comparaciones con mamografías
anteriores.
regilye,
egzamenthat
teteany
mwen
mwen menm
mwa,
ak konparezon
nenpòt
te fènow,
avan.it is my
b. I understand
timefèI develop
a newchak
breast
problem
OR if I amavèk
having
any mamogram
new breast mwen
problems
b.
______Initials
I understand
any time I and
develop
problem
OR iftime
I amofhaving
any new breast problems now, it
responsibility
to report
this tothat
my physician,
also atonew
the breast
technologist
at the
my mammogram.
is______Iniciales
my responsibility
to report
myque
physician,
alsoproblema
to the technologist
timeteniendo
of my mammogram.
Entiendo
que this
cadatovez
tenga unand
nuevo
de senos Oatsithe
estoy
nuevos problemas de senos
_____Inisyal
Mwen
konprann
nenpòt
lè
mwen
devlope
yon
nouvo
pwoblèm
nan
tete
OU
si
mwen
gen
nenpòt nouvo pwoblèm
ahora, es mi responsabilidad informar a mi médico así como a la tecnóloga en el momento de la mamografía.
nan
tete mwen kounye
a, se responsabilite
mwen pouforrapòte
sa bay mammogram
doktè mwen, ansanm
lè m ap fèI may
mamogram
c. I understand
that anytime
I have been scheduled
a screening
but haveaka teknolojis
new breastla problem,
need to
nan.
have a diagnostic mammogram and/or breast ultrasound, which my physician will need to order.
c.______Iniciales
______InitialsEntiendo
I understand
that anytime
I have una
beenmamografía
scheduled for
a screening
mammogram
haveuna new
que cada
vez que tenga
de detección
programada
perobuttenga
nuevobreast
problema de
problem,
may need
have que
a diagnostic
and/or
breast ultrasound,
which mydephysician
willmineed
to order.
senos, esI posible
quetotenga
hacermemammogram
una mamografía
de diagnóstico
o un ultrasonido
senos, que
médico
tendrá
que_____Inisyal
solicitar. Mwen konprann nenpòt lè mwen gen randevou pou yon egzamen mamogram men mwen gen yon nouvo
pwoblèm
nan tete,
kapab
bezwen
fè yon mamogram
poumammogram
detekte kansèresults.
ak/ou yon ekografi tete doktè mwen pral bezwen
d. I understand
thatmwen
I must
contact
my physician
for my final
kòmande.
______Iniciales Entiendo que debo comunicarme con mi médico para obtener los resultados finales de mi mamografía.
d. ______Initials I understand that I must contact my physician for my final mammogram results.
Patient
Signature/
______Inisyal
mwen konprann mwen oblije kontakte doktè mwen pou konnen rezilta final mamogram mwen an.
Patient Signature/Siyati Pasyan: _____________________________________ Date/Dat: ___________________
FOR TECHNOLOGIST USE ONLY: MRN# ______________
Technologist Comments: _____________________________________
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Revised 7-2012
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