Maria LoTempio - Plastic Surgery for Woman
 

Your Contact Information (*Denotes Required Fields)
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First Name:*
Last Name:*
E-Mail:*
Address:*
City:*
State:*
Zip:*
Home Phone:*
Cell Phone:
Fax:


"Getting to Know You!" (*Denotes Required Fields)
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Your Height:*
Your Weight:*
Breast Size:*
Age:*
Date of Birth:*


Primary Insurance (*Denotes Required Fields)
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Person Responsible for Account:*
Insurance Company:*
Insurance Company Phone:*
Insurance Company Address:*
Insurance Company City:*
Insurance Company State:*
Insurance Company Zip:*
Subscriber Number:
Group Number:
Primary Care Doctor:
Oncologist:
General Surgeon:


History of Present Breast Illness (*Denotes Required Fields)
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When Did the Breast Condition First Occur?:*


How was it Diagnosed?
Self Mammogram Physician Other

What side it the Tumor on?
Right Left Both N/A

What Type of Tumor (if known)?
DCIS Invasive Ductal Lobular

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)



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Have You Had Chemotherapy?* Yes No
Duration: From to
Medication:

Have You Had Radiation Therapy?* Yes No
Duration: From to
Medication:


A Little About Your Personal History (*Denotes Required Fields)
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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?


Lymphedema History (*Denotes Required Fields)
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Side:
Right Left Both N/A

Extremity:
Arm Leg 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

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Do You Bandage an Extremity?
Yes No

If Yes, When?
Daytime Nighttime Both N/A

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Do You Use a Pneumatic Pump?
Yes No
If Yes, How Often?

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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?
(ex: Lymphovenous Bypass)

How Would You Like to be Contacted?
Email Phone


* All information submitted on this form will be securly transmitted an kept confidential.
Contact - Dr. Maria LoTempio