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CBE RESULTS DOCUMENTATION FORM

Purpose of Visit Annual screening New problem Recall Short-term F/U ___mos. Other: __________________ Patient Concerns None Lump Nipple discharge Nipple skin retraction Erythema / swelling Rash / scaling Breast pain Other: ____________ Breast Findings None Fine nodularity Dense nodularity Skin edema Nipple/areolar change Tenderness Nipple discharge Mass Symmetry

R

Pt Name: ______________________________ ID #: __________________________________ DOB: __________________________________

Breast Cancer History Patient:AgeatDx______________ Mother:AgeatDx______________ Sister(s):Age(s)atDx___________ Daughter(s):Age(s)atDx________ Aunt(s):Age(s)atDx____________ Male Relative(s): _______________

specify relationship

Breast Health History

Date of Last CBE ________ Normal Abnormal Unknown

N/A N/A N/A N/A N/A N/A

L Cyclic Date Pt Found

R

L

________ ________ ________ ________ ________ ________ ________

O'Clock

Related Breast History Last Mammogram: ______________ (mo/yr) Last Menstrual Period: ___________ (mo/yr) # Breast Biopsy(s): 0 1-2 3Bxormore date(s): __________________________ # years HRT Use: 0 1-2 3 yrs or more last used ___________________ (mo/yr) Augmentation ________________ (mo/yr) Reduction ___________________ (mo/yr)

Distance from Nipple

Depth of Pressure

Physical Exam

Yes No

___________ ___________ ___________ ___________ ___________ ___________ ___________

________ ________ ________ ________ ________ ________ ________

___________ ___________ ___________ ___________ ___________ ___________ ___________

Discrete Mass Shape Margins Size round well-defined <5 mm oval ill-defined 5-9 mm irregular 1-2 cm 3-4 cm >4 cm Lymph Nodes Axillary WNL Enlarged Fixed Mobile

R

Texture Mobility Other soft fixed ______ firm mobile ______ rubbery hard Clavicular

Infra R L

L

Supra R L

+++ = scar /// = dimpling

·=

palpable mass = uncertain thickening

Overall Summary

Results

CBE Result Date___________ Normal Benignfinding Abnormality: suspicious for cancer

Imaging Referral Date___________ Screening imaging Diagnostic imaging Ultrasound (only) Other

Patient Education Importance of annual screen Referral follow-up Breastself-examination Other

Case Management

Clinician Signature for CBE: Date ___________ CBE & imaging results concordant ___________ CBE & imaging discordant ___________ Patientnotifiedofmammogramresults ___________ Patient informed and referred ___________ Referral for risk assessment counseling

Date: Date ____________ Radiology/imaging workup ____________ Surgical consult ____________ Return for CBE in 1 2 3 mos. ____________ Return for CBE in 6 mos. ____________ 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

February 2011

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