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This document is a Mammography History Sheet intended for office use to collect patient\'s medical history related to breast health and imaging studies.
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How to fill out mammography history sheet
How to fill out mammography history sheet
01
Start with personal information: Enter your name, date of birth, and contact details at the top of the sheet.
02
Fill in the date of your last mammogram: Write the date when you last had a mammogram performed.
03
List any previous mammograms: Provide details of any mammograms done in the past, including dates and locations.
04
Note your family history: Indicate if there are any breast cancer cases in your family tree, including immediate and extended family members.
05
Provide medical history: Fill out any relevant medical conditions, treatments, or surgeries related to your breast health.
06
Include information on hormone therapy: Specify if you are currently using hormone replacement therapy or any medications affecting breast tissue.
07
Sign and date the form: At the bottom, ensure you sign and date to confirm the accuracy of the information provided.
Who needs mammography history sheet?
01
Women aged 40 and over should complete a mammography history sheet as part of their routine screening process.
02
Individuals with a family history of breast cancer may also need to fill out a mammography history sheet regardless of age.
03
Patients experiencing breast symptoms or undergoing breast health surveillance may also require this documentation.
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What is mammography history sheet?
The mammography history sheet is a document that records a patient's previous breast imaging studies and related medical history, which helps healthcare providers understand the patient's background and make informed decisions about further screenings or treatments.
Who is required to file mammography history sheet?
Typically, healthcare providers or mammography facilities are required to file the mammography history sheet for patients undergoing a mammogram, to maintain accurate records and ensure continuity of care.
How to fill out mammography history sheet?
To fill out the mammography history sheet, patients or their healthcare providers should provide detailed information about previous breast imaging results, any prior breast surgeries or biopsies, family history of breast cancer, and current breast health status.
What is the purpose of mammography history sheet?
The purpose of the mammography history sheet is to document a patient's breast health history, facilitate communication among healthcare providers, and aid in identifying any changes or concerns that may require further investigation.
What information must be reported on mammography history sheet?
The mammography history sheet must report information such as previous mammogram dates and results, any breast-related surgeries or treatments, family history of breast cancer, personal health history, and any symptoms the patient is currently experiencing.
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