Yolanda Tammaro, M.D. Breast Surgery 1610 Route 88, Suite 203 Brick, NJ 08724 Phone: 732-840-3339 Fax: 732-785-8811
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Yolanda Tammaro, M.D. Breast Surgery 1610 Route 88, Suite 203 Brick, NJ 08724 Phone: 732-840-3339 Fax: 732-785-8811 Welcome to Our Practice! Your appointment is coming up and we want to insure you have the best possible experience in our office. Please review the checklist prior to your visit and be sure to have all items listed with you on the day of your visit. Please arrive 15 minutes prior to your scheduled time. Be sure to bring all of your Mammogram & Ultrasound (Sonogram) films and/or CDs with you for your appointment. Films and CDs cannot be faxed to our office and should be brought with you to your visit. Films are preferred but if the radiology facility only issues imaging on CDs that is accepted. You will need to call and have your dictated mammogram/ ultrasound/ MRI reports faxed to our office 3 days PRIOR to your visit. These reports (if possible) include any pathology reports from the breast procedures or needle biopsies/ aspirations you may have had in the past. Our fax line is: 732-785-8811. If your radiology was performed at a Meridian Health Hospital (Ocean Medical Center, Southern Ocean Medical Center, Riverview Medical Center, Jersey Shore University Medical Center or Bayshore Community Hospital, Meridian Health Village- Jackson) you are not required to bring your films/CDs nor have your dictated reports faxed to our office. Please fill out all paperwork enclosed with this letter and bring all paperwork with you to your appointment. We will need you insurance card and a photo ID, preferably a license. You will receive a phone call from our office a few days prior to your visit to confirm your appointment date and time. If you need to cancel or change your appointment, please let us know at least 24 hours in advance. You will also be required to make your co-payment prior to seeing Dr. Tammaro. We currently accept cash, checks and major credit cards including Visa and MasterCard. If your insurance requires a referral to see a specialist, it is your responsibility to obtain that referral from your primary care physician and present it when you come for your appointment, this may also be faxed to our office from your primary care physician BEFORE your appointment. We look forward to meeting you! Please contact us with any questions prior to your appointment at 732-840-3339. PATIENT HISTORY FORM Yolanda Tammaro, M.D. NAME: ____________________________________________ Age: ______ Date of Birth: _____/_____/_____ REASON FOR TODAY’S VISIT: ________________________________________________________________________ LIST ANY CHRONIC MEDICAL CONDITIONS: _________________________________________________________________ _______________________________________________________________________________________________________________ ___________________________________________________________________________________________ LIST PRIOR SURGICAL PROCEDURES: _______________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ ______________________________________________________________________ DATE OF LAST MENSTRUAL PERIOD: __________________ AGE OF FIRST MENSTRUATION: _________________ DATE OF LAST MAMMOGRAPHY: _______________________ DATE OF LAST PAP SMEAR: ____________________ HORMONAL REPLACEMENT THERAPY: NO YES OSTEOPOROSIS SCREENING: NO YES COLONOSCOPY: NO YES ANY BREAST BIOPSIES: NO YES If yes, at what age and diagnosis: __________________________________ HAVE YOU NOTICED ANY OF THE FOLLOWING: NIPPLE DISCHARGE: NO YES SKIN CHANGES: NO YES LUMP OR MASS: NO YES UNUSUAL PAIN: NO YES DO YOU: USE ALCOHOL: NO YES - OUNCES: ______/DAY USE CAFFEINE: NO YES - OUNCES: ______/DAY SMOKE: NO YES - PACKS: ______/DAY EXERCISE: NO YES IF YOU HAVE CHILDREN LIST SEX/AGES: ______________________________________________________________________________________________________________ _________________________________________________________________ AGE OF FIRST PREGNANCY: _____________________ BREAST/BOTTLE FEEDING: ___________________ ALLERGIES: NO YES If yes, what medication(s) and reaction? ___________________________________ _______________________________________________________________________________________________________________ FAMILY HISTORY OF BREAST CANCER: (If yes, then whom and age at diagnosis?) _______________________________________________________________________________________________________________ FAMILY HISTORY OF OTHER CANCERS: (If yes, then whom and age at diagnosis?) _______________________________________________________________________________________________________________ IS THERE ANYTHING ELSE I SHOULD KNOW ABOUT THIS VISIT? ______________________________________________________ REFERRING PHYSICIAN NAME & NUMBER: ________________________________________________________________________ ___________________________________________________ _______________ PATIENT SIGNATURE DATE Patient: ____________________________________________ DOB:____________________ Medication List Drug Dose Frequency Purpose Date Started/ Date Stopped Referring Physicians Patient Name: ________________________________________ DOB: _____/_____/_____ REFERRING PHYSICIAN Physician: ______________________________________ Specialty: ____________________ Address/Town: _______________________________________________________________ Phone: _______ - _______ - _______ Fax: _______ - _______ - _______ PRIMARY CARE PHYSICIAN Physician: ______________________________________ Specialty: ____________________ Address/Town: _______________________________________________________________ Phone: _______ - _______ - _______ Fax: _______ - _______ - _______ OTHER SPECIALTY PHYSICIANS Physician: ______________________________________ Specialty: ____________________ Address/Town: _______________________________________________________________ Phone: _______ - _______ - _______ Fax: _______ - _______ - _______ Physician: ______________________________________ Specialty: ____________________ Address/Town: _______________________________________________________________ Phone: _______ - _______ - _______ Fax: _______ - _______ - _______ Physician: ______________________________________ Specialty: ____________________ Address/Town: _______________________________________________________________ Phone: _______ - _______ - _______ Fax: _______ - _______ - _______ Yolanda Tammaro, M.D. Breast Surgery, Meridian Medical Group .