CENTER FOR BREAST DISEASES
PATIENT INFORMATION SHEET
Name
*
First Name
Middle Name
Last Name
Birthdate
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Age
*
Nationality
*
Gender
*
Male
Female
Others
Marital Status
Please Select
Married
Widowed
Separated
Divorced
Single
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Religion
*
Contact Number
*
Please enter a valid phone number.
Format: (+63) 000-000-0000.
Email address
*
example@example.com
Menarche (Age at first menstruation)
*
Last menstrual period (1st day)
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
No. of Pregnancies
*
No. of children
*
Please Select
1
2
3
4
5
6
7
8
9
10
Age at 1st pregnancy
*
Breastfeeding
*
Yes
No
Duration
Oral Contraceptives
*
Yes
No
Duration
Hormone Replacement theraphy
*
Yes
No
Duration
Menopause
*
Yes
No
Age of Menopause
Smoking History
*
Yes
No
No. of stick per day
Duration
Alcohol use
*
Yes
No
Duration
Previous breast surgery
*
Yes
No
Which side?
Left
Right
Both
Type
benign
maligant
Family History of Cancer: (Please check
*
breast
colon
Prostate
Stomach
ovary
lungs
others
Previous mammogram
*
Yes
No
Date of last exam
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Previous breast ultrasound
*
Yes
No
Date of last exam
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you perform breast self-examination
*
Yes
No
Medication taken:( if any)
Back
Next
Doctor Schedule
Please Select
Dr. Pineda
Dr. Ordonez
Dr. San Diego
Dr. Tison
Dr. Lim
Dr. Pineda - Appointment
Dr. Tison - Appointment
Dr. Ordonez - Appointment
Dr. Lim - Appointment
Dr. San Diego - Appointment
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