• Confidential Questionnaire for Women’s Health Check

  • Birthdate*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Please Mark Yes Or No As It Applies To You:

  • Any close relative ever had breast cancer?
  • Ever been diagnosed with breast cancer?
  • Diagnosed with any other breast disease? (Fibrocystic, Mastitis, Cystic, Abscess)
  • Any biopsy or surgery to your breasts?
  • Cosmetic surgery to breasts? (implants, reduction, lift) Left 5 Right 5 Date
  • Do you have dense breast tissue?
  • Have you had a mammogram in the past 12 months?
  • Have you had more than 30 mammograms in your lifetime?
  • Mammogram in the past 5 years? Date of most recent mammo or U/S
  • Any abnormal results from any breast testing?
  • Ever taken a contraceptive pill for more than 4 years? How long?
  • Ever diagnosed with ovarian, uterine or cervical cancer?
  • Ever taken hormone replacement therapy? (pharmaceutical or bio-identical)
  • Do you have an annual physical breast examination by a doctor?
  • Do you perform a monthly breast self-exam?
  • Did your periods start before the age of 12?
  • Did your periods end after the age 50?
  • Have you ever given birth to a child?
  • Have you ever smoked for more than 5 years?
  • Are you still having a menstrual cycle?
  • Is your menstrual cycle irregular?
  • Do you experience cramping during your menstrual cycle?
  • Do you have heavy bleeding with your menstrual cycle?
  • Do you have breast pain or tenderness that comes and goes?
  • Do you have any breast lumps that come and go?
  • Do you have low libido? (low sex drive)
  • Do you have hot flashes?
  • Have you ever been diagnosed with endometriosis?
  • Have you ever been diagnosed with PCOS (poly cystic ovarian syndrome)?
  • Have you ever been treated for infertility?
  • Do you have any swelling in the neck or trouble swallowing?
  • Any thyroid disorder? (hypothyroid/ hyperthyroid/ Hashimoto’s/ Grave’s disease)
  • Do you regularly experience fatigue?
  • Have you experienced recent hair loss?
  • Had a vaccination in last 4 weeks? Indicate which arm

  • Have you recently had any of these breast symptoms?

  • Mark Right Breast or Left Breast as it applies

  • Pain (Right Breast)
  • Pain (Left Breast)
  • Tenderness (Right Breast)
  • Tenderness (Left Breast)
  • Lumps (Right Breast)
  • Lumps (Left Breast)
  • Change in breast size (Right Breast)
  • Change in breast size (Left Breast)
  • Areas of skin thickening or dimpling (Right Breast)
  • Areas of skin thickening or dimpling (Left Breast)
  • Secretions of the nipple (Right Breast)
  • Secretions of the nipple (Left Breast)

  • PATIENT DISCLOSURE:

    I understand that the Report generated from my images is intended for use by trained healthcare providers to assist in evaluation, diagnosis and treatment. I further understand that the Report is not intended to be used by individuals for self-evaluation or self-diagnosis. I understand that the Report will not tell me whether I have any illness, disease, or other condition but will be an analysis of the images with respect only to the thermographic findings discussed in the Report.
    By signing below, I certify that I have read and understand the statements above and consent to the examination.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: