History Form for Breast Cancer

After breast cancer, it is a good idea to keep an ongoing list of key information. Over the years, I’ve encountered patients with varying diagnoses, who kept a card in their purse or wallet with an up to date list of their medications. I think it’s helpful to do something similar after breast cancer, with your important information and dates. This information evolves over time, and will need updating accordingly.

You may even want to make copies to give to providers at medical or therapy appointments. You can keep information to a single page and keep it in a page protector, or record it on a large index card (back and front) and laminate.

There are certainly a lot of reasons to do this. As time goes on, you may not always remember to include all key information, or may not remember dates or time frames.

Healthy Breast Tissue
Healthy Breast Tissue | Source

If you give primary care doctors, specialists, or therapists a concise copy of your pertinent information, they can better help you, they can make more informed decisions about your care, and it will be more likely that they will document correct history. They may even attach what you submitted. It’s a nice quick reference without having to digest a thick medical record, which may not be available anyway.

I am going to share the history form I prepared for my clients after breast cancer.



Provide the names of your doctors and specialists.  If they are not all associated with the same medical treatment center, provide address and contact phone number.  I would not delete anything.  You can indicate things like “radiation undecided at this time”, or none, meaning “I did not have radiation therapy”. 


PCM:  Primary Care Manager.  This would be your “family doctor”, Physician’s Assistant, or Nurse Practitioner that you see for routine medical care. 

Surgeon:  The surgeon who performed your mastectomy or lumpectomy: 

Oncologist/Chemo Doctor:  Who is the primary doctor managing your cancer treatment?  This is usually the doctor who manages your chemotherapy decisions. 

Radiation Oncologist:  Your radiation therapy radiologist. 

Plastics:  Your plastic surgeon if you had reconstruction. 


Dates of Surgeries


List your surgical procedures, with dates and any significant complications.  It may be helpful to do this chronologically. 








Number of Lymph Nodes Excised:  Include if you had preliminary biopsy “sentinel” node excised, then subsequent excision of additional nodes.

Drains:  Did you have drains placed at the time of your initial surgery?  If so how many, and how long were they in place? 

Chemotherapy Port:  Do you have a chemotherapy port?  When was it placed?  What is the location?  When was it removed?

Reconstruction:  Did you have reconstruction?  Was it at the same time as your mastectomy, or was it delayed?  When was your reconstruction surgery?  Was it staged over a period of time? 




Dates of treatment, or projected dates of pending treatment. 


Chemotherapy:  Did you have chemotherapy?  What was the frequency and duration?  What were your start and stop dates? 

Radiation:  Did you have radiation therapy?  What was your therapy schedule and dates? 

Physical/Occupational Therapy:  I was usually the first therapy experience for my clients.  Many clients never get referred for therapy after breast cancer.  Indicate if you had therapy, when, and for how long?  What was the therapy for?  Range of motion?  Scar management?  Lymphedema? 


Help Items


Have you been prescribed, or do you have any of the following items?  These products are often all available at businesses that cater to clients after breast cancer.  There is also good coverage for many items by insurers, which means a doctor’s referral is required. 


Camisole, Sports Bra or Mastectomy Bra:  If your bra does not fit well, you can ask for a referral for mastectomy bra fitting.  If you live in the U.S., breast cancer survivor volunteers meet with current breast cancer patients in many communities on behalf of the American Cancer Society.  My clients have told me the free mastectomy bra from the ACS is the most comfortable one they have tried. 

Breast Prosthesis:  Do you have an insert for your bra, a prosthesis?  Does it still fit?  Is it the right weight? 

Compression Sleeve:  Helpful for lymphedema prevention.  Do you have one, when did you get it, what is the pressure delivered (usually 20 to 40 mmHg), what is your wear schedule?

Compression Gloves or Gauntlets:  Same as for sleeves.  Do you wear sleeve and glove together, or do you sometimes wear one or the other? 

Wig (Cranial Prosthesis to payers):  Can be covered by insurers when prescription is written, usually by chemo doctor. 


Chronic/Significant Health Problems


Do you have high blood pressure, diabetes, thyroid disease etc?  What medications do you take? 


Current Concerns and Symptoms


Depending on the type of medical visit you are being seen for, you might want to prepare questions.  These are the areas I ask my clients about, who are referred to me for therapy after breast cancer: 


Shoulder Range of Motion:  Has your range of motion on your surgical side returned to your pre-surgery range? 

Pain:  Describe pain in terms of location, frequency, duration, and intensity on the 0-10 scale.  Is pain brief and sharp, or achy and lingering? 

Sensation/Numbness/Tingling:  Do you have areas of altered sensation, such as dull sensation around mastectomy incision/scar, or to armpit? 

Scars/Incisions:  What incisions/scars do you have- mastectomy, lumpectomy, chemo port, drains?  Are all incisions healed?  Were there complications or infections? 

Swelling/Lymphedema:  Have you been treated for, or suspected of having lymphedema?  Are you concerned about developing lymphedema?  Were you educated on lymphedema prevention? 


My History Form for Breast Cancer

My history intake form for breast cancer clients
My history intake form for breast cancer clients | Source

Get Breast Cancer History Form

You can view and print my Breast Cancer History Form on Google Drive through this link.

More by this Author


Princessa profile image

Princessa 6 years ago from France

Excellent advice and the best thing is that some of the tips can be applied to your health care in general.

Looking back I wish I had kept records of all the different treaments and surgeries I had over the years, it is specially important when you change towns and countries as you can not easily locate the doctors who treated you.

Lily Rose profile image

Lily Rose 6 years ago from East Coast

RM - Thank you!! This is something that I have meant to do for quite some time now. I went through so much with my breast cancer that it absolutely should be documented and with my chemo brain I've forgotten so much already ...I will be coming back here very soon to use your "go-by" for sure!

ImChemist profile image

ImChemist 6 years ago

I personally agree with you about keeping your history of breast cancer , this information can help doctors in the diagnosis and treatment of the cancer.

rmcrayne profile image

rmcrayne 6 years ago from San Antonio Texas Author

You bring up excellent points for me Princessa. I forgot about the 'general guide for most anyone' idea. I'll have to add it to my running list. I actually prepared something like that for some friends having difficulty getting their MDs' support on diagnosing thyroid disease. Easy for me to forget because the DoD has had electronic documentation for 6 years or so now, which is available world wide.

rmcrayne profile image

rmcrayne 6 years ago from San Antonio Texas Author

Thanks Lily. I went back linked to some breast cancer hubs, including several of yours. And I emailed you my template for history.

rmcrayne profile image

rmcrayne 6 years ago from San Antonio Texas Author

Thanks ImChemist. History is always important, but there are many special considerations related to different cancer treatments, making a good history doubly important.

Specialk3749 profile image

Specialk3749 6 years ago from Michigan

Very good advice! I have found that no matter what kind of medical procedure or surgery you have done, keeping good records of the event is very necessary. Even if it is just to jog your memory of the dates for when the time comes to fill out history information for a new doctor. (LOL, I'm getting older!)

rmcrayne profile image

rmcrayne 6 years ago from San Antonio Texas Author

Thanks for reading and commenting Specialk. I prefer to say "less young" rather than the "O" word.

cindyvine profile image

cindyvine 6 years ago from Cape Town

This is great and very useful! At the moment I still remember my history but think you are right in suggesting I write it down. Am floating a bit on pain meds, but my surgery Friday was successful, in that I have a breast which looks like my old one.

rmcrayne profile image

rmcrayne 6 years ago from San Antonio Texas Author

Wonderful to hear from you cindyvine! I'm glad your mastectomy and reconstruction went well. Let's continue with good news. I'll definitely keep you in my thoughts. Do you have more access to medical care this time? What about therapy? If not, please take my other breast cancer hubs to your doctor and see if he/she is okay with you following my recommendations for range of motion, scar management and lymphedema prevention.

Earthy Mother profile image

Earthy Mother 5 years ago from South East England

This is very interesting...I had a mastectomy last week and am about the face the results of what they found plus what treatment I will be receiving...I am somewhat concerned about lymphedema as my arm feels swollen but is not (my breast care nurse reckons I am fine) but I'm going to check out your other hubs now...Thanks for posting and voted up.

rmcrayne profile image

rmcrayne 5 years ago from San Antonio Texas Author

Earth Mother, thanks for visiting. I see you found your answer in my post-op management hub.

Earthy Mother profile image

Earthy Mother 5 years ago from South East England

I did indeed! Your treatment of scars is also of great interest to me so I'm glad I found you!! :-)

    0 of 8192 characters used
    Post Comment

    No HTML is allowed in comments, but URLs will be hyperlinked. Comments are not for promoting your articles or other sites.

    Click to Rate This Article