Contact Cadogan Clinic
Candidate Form




1. Your Contact Information

First Name
Last Name
Address
City
Zip
Phone
Additional Phone
E-mail

2. Getting to Know You!

Your Height
Your Weight
Breast Size
Your Age
Gender  Male Female
Month / Day / Year

3. Primary Insurance

Person Responsible for Account
Insurance Company
Insurance Company Phone
Address
City
Zip
Subscriber Number
Group Number
Primary Care Doctor
Oncologist / General Surgeon

4. History of Present Breast Illness

When Did the Breast Condition First Occur?*

How was it Diagnosed?
What side it the Tumor on?
What Type of Tumor (if known)?
What was the Size of the Tumor?
Number of Lymph Nodes Removed?
Number of Nodes Positive?
Date of Mastectomy
Mastectomy Surgeon
Date of Lumpectomy
Lumpectomy Surgeon
Date of Sentinel Lymph Node Procedure
Describe any other breast surgery you have had so far (including reconstruction if any)
Have You Had Chemotherapy?  Yes No
From/To/Medication
Have You Had Radiation Therapy?  Yes No
From/To/Medication

5. A Little About Your Personal History

What Age Your Period Began
Age at Your First Pregnancy
Number of Pregnancies / Number of Live Births
Date of Last Mammogram
Breast Lump or Discharge?  Yes No
Do You Breast Feed?  Yes No
Do You Do Regular Breast Self-Examinations?  Yes No
Personal Use of Birth Control Pills?  Yes No
Treatment for Infertility?  Yes No
Do You Still Have Your Ovaries?  Yes No
Have You Taken Estrogen Hormone Replacement Medications?  Yes No
Have You Had Generic Testing for the BRCA Gene Mutation?  Yes No
Results*

6. Lymphedema History (Please Fill in All Applicable Fields)

Side  Right Left Both N/A
Extremity  Right Left Both N/A
Have You Had Lymphatic Drainage by a Physical Therapist?  Yes No
Do You Wear a Compression Garment?  Yes No
If Yes, When?  Daytime Nighttime Both N/A
If Yes, What Pressure?  20-30 30-40 40-50 Not sure
Do You Use a Pneumatic Pump?  Yes No
If Yes, How Often?
Have You Had Any Infections Requiring Antibiotics?  Yes No
Have You Had Any Infections Requiring Hospitalization?  Yes No
How Many Infections Do You Have a Year?  0-2 3-5 6-10 11-15 +16
Have You Had Any Additional Treatment for Your Lymphedema?

7. Past Medical History

Have You Had Any of the Following? Heart Disease Arthritis Rheumatic Fever Anemia Tuberculosis Diabetes Blood Clots Glaucoma Asthma AIDS or HIV Stroke Hepatitis Stomach Ulcer Kidney Disease Throid Disease Bleeding Tendency Mitral Valve Prolapse High Blood Pressure
Drug Allergies*

8. Past Medical History

Please List Any Major Illnesses and Dates

Date (MM/DD/YEAR)
Illness
Date (MM/DD/YEAR)
Illness
Date (MM/DD/YEAR)
Illness

Please list all your past surgeries and dates

Date (MM/DD/YEAR)
Procedure
Date (MM/DD/YEAR)
Procedure
Date (MM/DD/YEAR)
Procedure

9. Current Medications

Please include asprins, ibuprofen, birth control pills, etc. and dosage.

Medication
Dosage
Medication
Dosage
Medication
Dosage
Medication
Dosage
Medication
Dosage

10. Bleeding Disorders

Have you or any of your relatives had problems with blood clots or bleeding?

11. Family History

Please list any blood relatives with cancer.

Type of Cancer
Relationship
Type of Cancer
Relationship
Type of Cancer
Relationship
Type of Cancer
Relationship
Type of Cancer
Relationship

12. Social History

Do you smoke?  Yes No
Type / Amount Per Day
Do you drink?  Yes No
Type / Amount Per Day
Occupation
Marital Status *
Spouse Occupation
Number of Children

13. Physical Activity Level

Does your work require any physical activity?  Yes No
Often Do You Exercise?
Do you have back pain?  Yes No
What Types of Activity Do You Enjoy?

14. Review of Symptoms

Have You Had Any of the Following? Weight Change Dry Eyes Chronic Cough Chest Pain Rapid Heat Beat Abdominal Pain Swollen Feet/Ankles Skin Rash Chronic Diarrhea Jaundice Depression Heartburn Reflux Seizures Joint or Muscle Pain Urinary Symptons Easy Bleeding Easy Bruising Swollen Lymph Nodes
Drug Allergies*