BREAST CANCER DETECTION AND CARE

REQUEST FOR MASTOGRAPHY

FOLIO
I. Unit identification II.Date of application
day month year
Medical Unit _________________ Delegation _____________________ Jurisdiction ______________

III. Patient identification

No.Affiliation|CURP ___________ _______|| ________Office ____________ M V
_______ year
Name ____________________ ________________ Age
Paternal Surname s
Mother's Last Name Name(s)
Address
Street and Colony
number I I I I I I I or Tel
Municipality or Delegation State Zip Code

IV. Clinical Examination Results_______V.History

of mastography [1] Yes No. [2]No
[1] Normal [2] Abnormal 5.2 Date of the last rm mastography
day month year
Name, Category and
Applicant's signature ___________________________________________ Enrollment:______________
RESULTS
VI. Date of mastography VII. Radiologic Technician Registration_____________
day month year
VIII. Quality of mastography IX. Date of interpretation rm
day month year
[ ] Full breast image [Nipple perpendicular to the breast [ ] Adequate compression
Symmetric breast images [ ] Appropriate exposure [ ] Inadequate for
interpretation [ ] Inadequate for interpretation

X. Radiological findings D I

If inadequate, specify the cause

DI
[asymmetric BREAST DENSITY oo
o o [ ] NODULE OR MASS
[ALMOST ENTIRELY FATTY (< 25% FIBROGLANDULAR) SHAPE__________________
[DISPERSED FIBROGLANDULAR ( 25-50% FIBROGLANDULAR) SIZE_____________CM
[ ] HETEROGENEOUS (51-75% FIBROGLANDULAR) [microcalcifications
[EXTREMELY DENSE (<75% FIBROGLANDULAR) [ ] MACROCALCIFICATIONS

XI.Diagnosis (BIRADS) DI
[ 0] INCONCLUSIVE STUDY [ 1] [3] PROBABLY BENIGN
NORMAL BREAST [ 2] BENIGN [4] PROBABLY MALIGNANT
FINDINGS [ 1] NORMAL BREAST [ 2] [5] MALIGNANT FINDINGS
BENIGN FINDINGS
Remarks
XII. Conduct to be followed
[ 1] Detection in two years [3] Evaluation in a short time (6 months)
[ 2] Repeat mastography due to technical failure [4] Reference for diagnostic evaluation
XII. Name and signature of radiologist__________________________ Enrollment:_______________
XIV. Report the result to the woman XV. Reference 1.5.1 Date
day month year
Illi 1.5.2 Unit _______________ Delegation_______________
day month year