Your Contact Information

Getting to Know You!

Gender

Primary Insurance

Secondary Insurance (If Applicable)

History of Present Breast Illness

Have You Had Chemotherapy?

Have You Had Radiation Therapy?

A Little About Your Personal History

Breast Lump or Discharge?

Do You Breast Feed?

Do You Do Regular Breast Self-Examinations?

Personal Use of Birth Control Pills?

Treatment for Infertility?

Do You Still Have Your Ovaries?

Have You Taken Estrogen Hormone Replacement Medications?

Have You Had Generic Testing for the BRCA Gene Mutation?

Lymphedema History (*Please Fill in All Applicable Fields)

Side

Extremity

Have You Had Lymphatic Drainage by a Physical Therapist?

Do You Wear a Compression Garment?

If Yes, When?

If Yes, What Pressure?

Do You Bandage an Extremity?

If Yes, When?

Do You Use a Pneumatic Pump?

Have You Had Any Infections Requiring Antibiotics?

Have You Had Any Infections Requiring Hospitalization?

How Many Infections Do You Have a Year?

Past Medical History

Past Medical History

Please List Any Major Illnesses and Dates

Date (MM/DD/YEAR) Illness

Please list all your past surgeries and dates

Date (MM/DD/YEAR) Procedure

Current Medications

Please include asprins, ibuprofen, birth control pills, etc. and dosage.

Medication Dosage

Bleeding Disorders

Family History

Please list any blood relatives with cancer.

Type of Cancer Relationship

Social History

Do you smoke?

Do you drink?

Physical Activity Level

Does your work require any physical activity?

Do you have back pain?

Review of Symptoms

Contact Information

New York Office
630 3rd Avenue Suite 601
New York, NY 10017
1-888-890-3437
info@diepflap.com
New Orleans Office
2525 Severn Ave. 4th Floor
Metairie, LA 70002
1-888-890-3437
info@diepflap.com

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