DRCTC Ultrasound Breaset

NAME

Date

D.O.B

Age

REFERRING PHYSICIAN

REASON FOR EXAM (SYMPTOMS)

WHEN DID SYMPTOMS FIRST BEGIN?

SURGICAL HISTORY

PREVIOUS RADIOLOGY/ULTRASOUND STUDIES

ANY PERSONAL HISTORY OF THE FOLLOWING:

THYROID

BLADDER

PLEASE LIST :

BREAST- PRIOR MAMMO

Yes No

WHERE ?

WHEN ?

PALPABLE LUMP

Yes No

WHERE ?

How Long ?

HISTORY OF: CYST MASS NIPPLE DISCHARGE PAIN

Yes No

IF YES TO ANY WHERE?

*NO ULTRASOUND WILL BE READ WITH OUT PRIOR MAMMO FILMS*

FOR MEN ONLY:

TESTICLE

PAIN IF YES RT OR LT HOW LONG?:

ANY TRAUMA TO AREA?

Yes No

IF YES WHEN?

I accept to above all terms and condition