Breast and Cervical Cancer Control Program (Bcccp) Screening Form

BREAST AND CERVICAL CANCER CONTROL PROGRAM (BCCCP) BREAST FOLLOW-UP FORM

Patient Last Name ______First Name ______Birth Date ______Enrollment/Clinic Site: ______BREAST FOLLOW-UP  Follow-up Clinical Breast Exam  Diagnostic Mammogram  Ultrasound  Result from non-BCCCP Provider  Result from non-BCCCP Provider  Result from non-BCCCP Provider

Office Visit Date: ______Date Performed: ______Date Performed______Facility/Provider: ______Facility/Provider: ______Facility/Provider:______R Follow-up CBE Results L R Mammogram Results L R Ultrasound Results L  No Breast Abnormality   ACR 1: Negative   ACR 1: Negative   Benign Breast Condition   ACR 2: Benign Finding   ACR 2: Benign Finding   Probably Benign   ACR 3: Probably Benign   ACR 3: Probably Benign  Abnormal Breast Exam  ACR 4: Suspicious Abn.   ACR 4: Suspicious Abn.   ____Dominant mass   ACR 5: Suggestive of   ACR 5: Suggestive of  ____Nipple Discharge Malignancy Malignancy. ______ ACR 0: Additional work-up   ACR 0: Additional work-  ____Asymmetric Thickening/ required up required Nodularity ____Skin Changes______ Not Indicated/Omitted   Not Indicated/Omitted  ____Other______

 Not Indicated/Omitted   Short term follow-up:   Short term follow-up:  Repeat in ______months Repeat in ______months BREAST DIAGNOSTIC PROCEDURES Procedure Date of Service Facility/Clinic/Provider  Breast (Surgical) Consultation  Biopsy: Type of Biopsy______Specify Units (# Specimens) ______ Fine Needle Aspiration Specify Units (# Specimens)______ Cytology exam breast or nipple aspirate  Post Biopsy Mammogram (clip/wire placement)  Other Diagnostic Procedure ______WORKUP DISPOSITION Is Client work-up: Breast Cancer Treatment Disposition  Complete  Pending  Refused (Complete ONLY if LCIS, DCIS, or Invasive Breast Cancer Diagnosed) Interrupted (specify):  Treatment not needed  Moved  Seeing Non-BCCCP Provider  Cannot locate client  Treatment started, Date: ______ Deceased  Other______Type of Treatment: (Specify) ______Breast Final Diagnosis Date ______(Date of Last Diagnostic Exam)  Treatment pending: (state reason) ______R  Not Applicable (for work-up interrupted or refused) L  Treatment refused: (state reason) ______ Not Breast Cancer, Other______ Moved out of area  Ductal Carcinoma Insitu  Cannot locate  Lobular Carcinoma Insitu  Deceased  Cancer Invasive  Unknown

Revised July 2013