Breast Lump Evaluation Intake Form
Use this form to share the information needed for a breast lump evaluation, including your symptoms, history, and contact details.
Patient Information
First name
*
Last name
*
Date of birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex assigned at birth
*
Female
Male
Intersex
Prefer not to say
Other
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
example@example.com
Preferred contact method
*
Phone call
Text message
Email
No preference
Other
Breast Lump Details
Which breast is affected?
*
Left
Right
Both
Not sure
Exact location of the lump
When did you first notice the lump?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Has the lump changed in size?
No change
Getting larger
Getting smaller
Not sure
How would you describe the lump's feel?
Soft
Firm
Hard
Rubbery
Lumpy
Not sure
Is the lump painful or tender?
No
Yes, painful
Yes, tender
Not sure
Are the symptoms constant or intermittent?
Constant
Intermittent
Not sure
Which of the following are you experiencing?
Nipple discharge
Skin changes
Redness
Swelling
Warmth
Other
Additional details about the lump or symptoms
Associated Symptoms and Medical History
Associated Symptoms
*
Fever
Unintentional weight loss
Fatigue
Axillary lump or swollen lymph nodes
None of these
Other
Menstrual Status
Currently menstruating
Perimenopausal
Postmenopausal
Not applicable
Other
Last Menstrual Period
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pregnancy Status
Pregnant
Not pregnant
Unsure
Not applicable
Breastfeeding Status
Currently breastfeeding
Not currently breastfeeding
Recently stopped
Not applicable
Prior Breast Lumps or Biopsies
Prior breast lump
Prior breast biopsy
Prior benign breast condition
None
Other
Prior Breast Imaging
Mammogram
Breast ultrasound
Breast MRI
None
Other
Current Medications, Including Hormones or Birth Control
Allergies
Personal History of Breast Disease or Breast Cancer
Yes
No
Unsure
Family History of Breast or Ovarian Cancer
Yes
No
Unsure
Evaluation Consent and Clinical Acknowledgment
Patient Signature
*
Submit Intake
Submit Intake
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