Mastectomy Post-Op Patient Progress Form
Patient Name
Medical Record #
Date of Visit
Date of Birth
Surgery Date
Side of Surgery
Left
Right
Bilateral
Patient's Symptoms/Subjective Report
Current Concerns
Wound/Incision Assessment
Incision Healing
Healing Well
Delayed Healing
Signs of Infection
Drain Site
Intact
Discharge
Removed
Additional Assessment Notes
Arm/Shoulder Mobility
Full Range
Limited
Signs of Lymphedema
None
Present
Pain Level (0-10)
Plan/Recommendations
Clinician/Provider Name