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Breast Cancer

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/Breast Cancer
/Application Form

Breast Cancer

Please fill in the form completely.

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Patient Information

Full Name *

Age *

Gender *

What is your complaint?

What are your complaints?

I do not have any

Palpable mass in the breast

Nipple discharge

Other Complaints

Write your story about your illness.

When did your symptoms start?

Please inform us about the history of your illness:

Your additional diseases:

Previous surgeries (if any):

Please state the medications you take on a regular basis (with doses)

Do you have a first or second degree relative with breast cancer?

If yes, please indicate:

Have you had any previous treatment for this disease?

Did you receive any treatments for this disease before?

I did not receive any treatments for breast cancer before

Hormone therapy

Radiation therapy

Drug therapy (Chemotherapy)

Treatment Start Date

Treatment End Date

Treatments You Received

Treatment Start Date

Treatment End Date

Radiotherapy Doses You Have Received

Treatment Start Date

Treatment End Date

Treatments You Received

Pathology Reports

Needle Biopsy Report

Open Biopsy Report

Pathology Report of the Breast Surgery if Performed

Imaging (Radiology) Reports

Breast Ultrasonography

Mammography

MRI of the Breast

Complete Ultrasonography of the Abdomen

FDG - PET CT

MRI of the Brain

Whole Body Bone Scintigraphy

Thorax (Chest) CT

Galactrography

Laboratory Examinations

Hemogram (Complete Blood Count) Report

Biochemistry Report

I have read and understood the Information and Consent Text regarding the Provision of Remote Healthcare Services and hereby accept its terms.*

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