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Data de Nascimento:_________________ Idade: _________

Sexo:___________________ Tel:___________________ Convênio:________________

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Queixa principal

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História da doença atual

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Patologias / cirurgias mamárias prévias

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Exame Físico

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Perfil psico-social

⃝ Atividade física ⃝ Tabagismo ⃝ Etilismo ⃝ Drogadição ⃝ DST

Menarca____________________________

G_________ P____________ A___________ Aleitam___________

Menop_______________ Aco___________________________

T.H_________________________ H.F___________________________

Cirurgias______________________________________________________

Tabag________________________________________________________

Exames

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Exame Físico

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Nova Imagem

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HD

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Conduta

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