Mastitis Diagnostic Evaluation Form
Please complete this form to support the evaluation of mastitis symptoms. Only provide information relevant to the diagnostic process.
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you currently lactating?
*
Yes
No
Duration of Symptoms (in days)
*
Location of Affected Area
*
Left breast
Right breast
Both breasts
Describe the main symptoms observed
*
Redness
Swelling
Warmth
Pain/Tenderness
Fever/Chills
Other
Rate the severity of pain
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Have you had mastitis before?
*
Yes
No
Have you received any treatment for this episode?
*
No treatment yet
Antibiotics
Analgesics
Other
List any recent breast trauma, procedures, or underlying conditions
Additional notes or observations
Submit Evaluation
Should be Empty: