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PORT ST. LUCIE FACILITY
UPRIGHT MRI
16 SLICE LOW DOSE CT SCAN
DIGITAL X-RAY
ULTRASOUND
DEXA SCAN
CT VIRTUAL COLONOSCOPY
3D TOMO MAMMOGRAPHY
3D BREAST ULTRASOUND
ELASTOGRAPHY/FIBROSCAN
FORT PIERCE FACILITY
OPEN HIGH FIELD 1.5T MRI
16 SLICE LOW DOSE CT SCAN
MRI GUIDED BREAST BIOPSY
BREAST MRI
PROSTATE MRI
DIGITAL X-RAY
ULTRASOUND
3D BREAST ULTRASOUND
DEXA SCAN
CT VIRTUAL COLONOSCOPY
3D TOMO MAMMOGRAPHY
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Mammography Form
DRCTC Mammography Patient history
Patient Name :
Doctor's Name :
D.O.B:
Age:
Radiology
Techonologist :
Date :
Previous Mammograms?
When.?
Films Sent For ?
Location :
Previous Breast Surgery :
Yes
No
Biopsy
Reduction
Implants
Mastectomy
Lumpectomy
Right
Left When ?
Results
Right
Left When ?
Right
Left When ?
Right
Left When ?
Chemotherapy?
Right
Left When ?
Radiation Therapy?
Number Of Pregnancies
Hormone History
Age at First Period
Last Menstrual Cycle :
Age of Menopause
Hysterectomy?
Oophorectomy
Family History of Breast Cancer :
Mothre
Sister
Daughter
Aunt
Othre
No
Any Complaints? :
Nipple Discharge?
Color:
Duration
Any Scars,Marks,or Moles? :
Lump ?
Right
Left
Pain ?
Right
Left
