Contact The Wilmslow Hospital
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 MaleFemale
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? YesNo
From/To/Medication
Have You Had Radiation Therapy? YesNo
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? YesNo
Do You Breast Feed? YesNo
Do You Do Regular Breast Self-Examinations? YesNo
Personal Use of Birth Control Pills? YesNo
Treatment for Infertility? YesNo
Do You Still Have Your Ovaries? YesNo
Have You Taken Estrogen Hormone Replacement Medications? YesNo
Have You Had Generic Testing for the BRCA Gene Mutation? YesNo
Results*

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

Side RightLeftBothN/A
Extremity RightLeftBothN/A
Have You Had Lymphatic Drainage by a Physical Therapist? YesNo
Do You Wear a Compression Garment? YesNo
If Yes, When? DaytimeNighttimeBothN/A
If Yes, What Pressure? 20-3030-4040-50Not sure
Do You Use a Pneumatic Pump? YesNo
If Yes, How Often?
Have You Had Any Infections Requiring Antibiotics? YesNo
Have You Had Any Infections Requiring Hospitalization? YesNo
How Many Infections Do You Have a Year? 0-23-56-1011-15+16
Have You Had Any Additional Treatment for Your Lymphedema?

7. Past Medical History

Have You Had Any of the Following?Heart DiseaseArthritisRheumatic FeverAnemiaTuberculosisDiabetesBlood ClotsGlaucomaAsthmaAIDS or HIVStrokeHepatitisStomach UlcerKidney DiseaseThroid DiseaseBleeding TendencyMitral Valve ProlapseHigh 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? YesNo
Type / Amount Per Day
Do you drink? YesNo
Type / Amount Per Day
Occupation
Marital Status *
Spouse Occupation
Number of Children

13. Physical Activity Level

Does your work require any physical activity? YesNo
Often Do You Exercise?
Do you have back pain? YesNo
What Types of Activity Do You Enjoy?

14. Review of Symptoms

Have You Had Any of the Following?Weight ChangeDry EyesChronic CoughChest PainRapid Heat BeatAbdominal PainSwollen Feet/AnklesSkin RashChronic DiarrheaJaundiceDepressionHeartburn RefluxSeizuresJoint or Muscle PainUrinary SymptonsEasy BleedingEasy BruisingSwollen Lymph Nodes
Drug Allergies*