Mastectomy Post-Operative Follow-up Form
Patient Information
Patient Name
Date of Birth
Visit Date
Surgery Details
Surgery Date
Side
Left
Right
Bilateral
Type of Mastectomy
Simple
Modified Radical
Skin Sparing
Nipple Sparing
Physical Examination
Wound Assessment
Drains Present
None
Yes
Seroma/Hematoma
No
Yes
Signs of Infection
No
Yes
Other Findings
Symptoms
Pain (0-10)
Mobility Limitation
No
Yes
Lymphedema
No
Yes
Interventions/Plan
Interventions/Plan
Next Visit
Further Follow-up Needed
No
Yes
Clinician
Clinician Name
Signature
Date