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Mammography
Patient Questionnaire
PATIENT:ACCESSION #: ___
STUDY: ___
DOS: ___MRN:DOB:All replies are confidential. Please answer all questions.
PREVIOUS MAMMOGRAMSHave you had a mammogram in the
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What is mammography patient history questionnaire?
The mammography patient history questionnaire is a form that collects relevant medical history information from patients prior to undergoing a mammogram.
Who is required to file mammography patient history questionnaire?
Healthcare providers or imaging facilities conducting mammograms are required to have patients fill out the mammography patient history questionnaire.
How to fill out mammography patient history questionnaire?
Patients can fill out the mammography patient history questionnaire by providing accurate information about their medical history, including any previous surgeries, family history of breast cancer, and current medications.
What is the purpose of mammography patient history questionnaire?
The purpose of the mammography patient history questionnaire is to help healthcare providers assess the patient's risk factors and ensure that the mammogram is conducted safely and effectively.
What information must be reported on mammography patient history questionnaire?
Information such as previous breast surgeries, family history of breast cancer, medication use, and any current breast symptoms must be reported on the mammography patient history questionnaire.
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