CBE Result Date___________ Normal Benign finding Abnormality: suspicious for cancer Overall Summary
Case Management
Breast Cancer History Patient: Age at Dx ______________ N/A Mother: Age at Dx ______________ N/A Sister(s): Age(s) at Dx ___________ N/A Daughter(s): Age(s) at Dx ________ N/A Aunt(s): Age(s) at Dx ____________ N/A Male Relative(s): _______________ N/A specify relationship Related Breast History Last Mammogram: ______________ (mo/yr) Last Menstrual Period: ___________ (mo/yr) # Breast Biopsy(s): 0 1-2 3 Bx or more date(s): __________________________ # years HRT Use: 0 1-2 3 yrs or more last used ___________________ (mo/yr) Augmentation ________________ (mo/yr) Reduction ___________________ (mo/yr)
Discrete Mass Shape Margins Size Texture Mobility Other round well-defined 4 cm Lymph Nodes Axillary Clavicular Supra Infra
Pt Name: _ ______________________________ ID #: ___________________________________ DOB: ___________________________________
R
L
+++ = scar /// = dimpling
•=
palpable mass = uncertain thickening
Imaging Referral Date___________ Patient Education Screening imaging Importance of annual screen Diagnostic imaging Referral follow-up Ultrasound (only) Breast self-examination Other Other
Clinician Signature for CBE: Date: Date Date ___________ CBE & imaging results concordant ____________ Radiology/imaging workup ___________ CBE & imaging discordant ____________ Surgical consult ___________ Patient notified of mammogram results ____________ Return for CBE in 1 2 3 mos. ___________ Patient informed and referred ____________ Return for CBE in 6 mos. ___________ Referral for risk assessment counseling ____________ Return in one year for annual CBE Other ___________________________________ Final Diagnosis Date_____________ Diagnosis_______________________________________________________________ Clinician Signature: Date: Sample document courtesy of the California Department of Public Health, Cancer Detection Section
