Mammography Centers, Information on Breast Exams, Mammogram Facts, and Breast Cancer.

This online journal is an anonymous worksheet designed for you to print and take to your doctor upon your next annual check up. It enables you and your doctor to communicate clearly any findings you have from your history and your monthly self-examinations. The information you provide is not stored and will not be maintained by MedTech.

Medical History

Date of Birth	January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
	I have had a hysterectomy. Date:
	I am currently taking estrogen.
Medication History What medications? For how long?
Pregnancy History How many? Miscarriages?
Age at First Pregnancy
	I breast fed one or more of my children.
Family History Relatives with Cancer? What types?
Alcohol Usage	I do not drink alcohol at all I rarely drink alcohol I drink socially and/or sometimes at dinner I drink heavily on a weekly basis I am an alcoholic
Mammogram History	Where was your last mammogram done? Who was your doctor?

Self-Examination Results
Click the portion of the breast in which you find any new lumps or abnormalities (dimpling, pain, etc.) in your breasts and give a description of what you found in the matching blank below.

Right Breast: Upper, Outside Quadrant

Describe what you found in the upper outside portion of your right breast.

Right Breast: Upper, Inside Quadrant

Describe what you found in the upper inside portion of your right breast.

Right Breast: Lower, Outside Quadrant

Describe what you found in the lower outside portion of your right breast.

Right Breast: Lower, Inside Quadrant

Describe what you found in the lower inside portion of your right breast.

Left Breast: Upper, Outside Quadrant

Describe what you found in the upper outside portion of your left breast.

Left Breast: Upper, Inside Quadrant

Describe what you found in the upper inside portion of your left breast.

Left Breast: Lower, Outside Quadrant

Describe what you found in the lower outside portion of your left breast.

Left Breast: Lower, Inside Quadrant

Describe what you found in the lower inside portion of your left breast.

Nipples

Describe any discharge or changes to your nipples. Be sure to specify which breast.