Mammography Clinical History

In an effort to create a minimal contact experience, we ask you to please fill out this health form prior to arriving for your mammography appointment.

Please do not fill this form out earlier than one week before your appointment.

If you have any questions regarding this form, please call 1-800-ROSWELL (1-800-767-9355).

Fields marked with an asterisk * are required.

Personal Information

About You

Are you calling for yourself, or on behalf of someone else? *

About The Patient

At which location are youis the patient receiving your their mammogram? *

Clinical History

Changes in breasts & nipples

Do youDoes have any NEW problems in your their breasts since your last mammogram (lump, discharge, etc)? *
Which side is the problem on? *
The problem was felt by: *

Cancer & breast surgery history

Have youHas ever had any breast biopsies or breast surgeries? *
Have youHas ever had a breast removed? (mastectomy) *
Which side was the mastectomy on? *
Have youHas ever had breast cancer? *
Which side was the cancer on? *
Have youHas ever had any other cancer diagnosis? *
Have youHas ever had radiation to yourtheir breasts? *
Do youDoes have breast implants? *

Family history

Do you haveDoes have a family history of ovarian cancer? *
Do you haveDoes have a family history of breast cancer? *
Do youDoes or anyone in yourtheir family have a known gene mutation? *
Which gene is the mutation in? *

General health

Have youHas had any vaccinations within the last 6 months? *
Arm youArm received vaccination in? *
Do youDoes take any of the following? *
Do youDoes have a menstrual period? *
Are youIs pregnant? *
Have youHas ever had a mammogram before? *

Lung Health

Within the last 15 years (including the present) have you smoked cigarettes? *
Have you smoked the equivalent of 1 pack a day for 30 years (OR 2 packs a day for 15 years)? *

Roswell Park Comprehensive Cancer Center offers a lung cancer screening program.
Based on the information you provided, you may be eligible. A patient access representative will be in contact with you about scheduling this appointment, which includes a low-dose CT scan to screen your lungs for early lung cancer.

Your Patient's Contact information

Contact Methods

What is the best method to contact you the patient? *

Your Patient's Residential Address