Sample Pre-Mammography Questionnaire

Before receiving a mammogram, women are usually required to fill out detailed questionnaires. Information pertaining to a personal and family medical history, previous mammograms and other breast imaging tests, etc. will be collected to help the radiologist render the most accurate assessment of the woman's mammogram. Below are a few examples of sample mammography questionnaires. It is important for women to bring the necessary information with them to answer these questions. Women should also bring their prior mammogram films if they are having a mammogram at a new facility.

 
Sample Pre-Mammography Questionnaires (Need Adobe Acrobat Reader):

Sample 1	Sample 2

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Sample Pre-Mammography Questions:

1. Please provide your name/date of birth/ address/ telephone:
2. Do you have breast implants? (yes/no)
3. Is this a follow-up to an abnormal mammogram? (yes/no)
4. Do you have any breast problems such as a lump, pain or discharge? (yes/no and if "yes", describe:__________________________________________________)
5. Did you or your doctor feel a lump in your breasts? (yes/no, if "yes", where? ________________ and how long has it been there?________________________)
6. Have you had breast cancer without the removal of your breast? (yes/no, if "yes" did you have radiotherapy (yes/no) or chemotherapy (yes/no)?))
7. Have you had previous breast surgery or biopsy? (yes/no, if "yes which side was it done on (right/left/both), in what month and year when was it performed ______?, and what was found ____________________?)
8. Has any blood relative has breast cancer? ( yes/no)
9. What is your age?
10. Are you still having menstrual periods? (yes/no)
11. Are you taking hormone therapy (yes/no, if "yes", what type:_______________)
12. Are you pregnant or nursing? (yes/no)
13. Do you have breast tenderness or pain at any time during the month? (yes/no, if "yes", schedule mammogram when breasts are less tender.)
14. If you have pain, is it in one spot? (yes/no)
15. Have you had a mammogram before? (yes/no, if "yes", where was it done ________and how long ago __________?)
16. Information on your primary physician or health care provider (name/address/telephone):
17. When was the last time you saw your health care provider?
18. Do you have written referral (prescription) for this mammogram (yes/no, if "yes", please provide referral form)
19. Does your healthcare provide know that you are scheduling mammography? (yes/no, if "no" the provider should be informed)
20. Is there any other information that would be helpful for us to know?

Notes:

1. If the answer to any of items 2, 3, 4 or 5 is "yes", diagnostic mammography will be performed. If the answer to each is "no", screening mammography will be performed.
2. If a previous mammogram was performed at another location, the name and contact information of the location that performed the previous mammogram should be provided or the previous films should be provided to the current mammography location)

Updated: December 17, 2007